Provider Demographics
NPI:1366520637
Name:LOGAN, ELISHA (MA,LPC, LADC)
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MA,LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-4611
Mailing Address - Country:US
Mailing Address - Phone:203-338-0669
Mailing Address - Fax:
Practice Address - Street 1:92 TURTLE BAY DR
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-4980
Practice Address - Country:US
Practice Address - Phone:760-672-0361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00383101YA0400X
CT6181101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)