Basic Information
| Provider Information | |||||||||
| NPI: | 1871888107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGSTON | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 VONDERBURG DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 VONDERBURG DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 03/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA11849 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 2355S0801X | SI1960 | FL | N | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 222Q00000X | SA11849 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 004084700 | 05 | FL | MEDICAID | 008214600 | 05 | FL | MEDICAID |