Provider Demographics
NPI:1104065564
Name:PENCE, LOGAN M (LICDC)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:M
Last Name:PENCE
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 N BARRON ST
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320-1704
Mailing Address - Country:US
Mailing Address - Phone:937-456-7694
Mailing Address - Fax:937-456-7753
Practice Address - Street 1:228 N BARRON ST
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-1704
Practice Address - Country:US
Practice Address - Phone:937-456-7694
Practice Address - Fax:937-456-7753
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH943841101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)