Provider Demographics
NPI:1528720703
Name:GREEN, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:GREEN
Suffix:
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 1:980 CONGDON AVE UNIT 8
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-3102
Mailing Address - Country:US
Mailing Address - Phone:309-335-9614
Mailing Address - Fax:
Practice Address - Street 1:106 S LINCOLNWAY STE A
Practice Address - Street 2:
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-1597
Practice Address - Country:US
Practice Address - Phone:815-757-7966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health