Provider Demographics
NPI:1104293109
Name:KALETA, LOGAN (PSYD, CIC)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:KALETA
Suffix:
Gender:M
Credentials:PSYD, CIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5597 N DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334
Mailing Address - Country:US
Mailing Address - Phone:954-958-4800
Mailing Address - Fax:
Practice Address - Street 1:5597 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334
Practice Address - Country:US
Practice Address - Phone:954-958-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10205103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist