Basic Information
| Provider Information | |||||||||
| NPI: | 1437747623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | LOGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 E LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950764424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317286445 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 411 E LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950764424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317286445 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2021 | ||||||||
| LastUpdateDate: | 01/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | AMFT123198 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.