Provider Demographics
NPI:1154550697
Name:LOGAN, ARLISS (PSYD)
Entity type:Individual
Prefix:DR
First Name:ARLISS
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29488 WOODWARD AVE # 204
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0903
Mailing Address - Country:US
Mailing Address - Phone:408-466-0318
Mailing Address - Fax:
Practice Address - Street 1:1843 R W BERENDS DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4955
Practice Address - Country:US
Practice Address - Phone:616-773-2908
Practice Address - Fax:616-532-3046
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103T00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program