Provider Demographics
NPI:1104471135
Name:LOGUE, DAVID ALLEN II
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:LOGUE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 ARROWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7503
Mailing Address - Country:US
Mailing Address - Phone:707-284-2950
Mailing Address - Fax:
Practice Address - Street 1:440 ARROWOOD DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7503
Practice Address - Country:US
Practice Address - Phone:707-284-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)