Basic Information
| Provider Information | |||||||||
| NPI: | 1477939577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRIAN | ||||||||
| FirstName: | LOGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5674 STONERIDGE DR. SUITE 207 | ||||||||
| Address2: | |||||||||
| City: | KENSINGTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947081143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255200005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5674 STONERIDGE DR. SUITE 207 | ||||||||
| Address2: | |||||||||
| City: | KENSINGTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947081143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255200005 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2015 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 95052415 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.