Provider Demographics
NPI:1366122681
Name:LOGAN, DOMINGA
Entity type:Individual
Prefix:
First Name:DOMINGA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 COMMERCIAL STREET
Mailing Address - Street 2:3RD FLOOR,
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 COMMERCIAL STREET
Practice Address - Street 2:FLOOR 3
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health