Basic Information
| Provider Information | |||||||||
| NPI: | 1780299610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LAC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 880 | ||||||||
| Address2: | |||||||||
| City: | ST IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598650880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 308 MISSION DR | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598659676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067454409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2020 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | BBH-ACLC-LIC-37537 | MT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.