Provider Demographics
NPI:1588757835
Name:LOGAN, SANDRA GAILYA (PHD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:GAILYA
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5322 PRIMROSE LAKE CIR
Mailing Address - Street 2:SUITE G
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3659
Mailing Address - Country:US
Mailing Address - Phone:813-866-8705
Mailing Address - Fax:813-333-2202
Practice Address - Street 1:5322 PRIMROSE LAKE CIR
Practice Address - Street 2:SUITE G
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3659
Practice Address - Country:US
Practice Address - Phone:813-866-8705
Practice Address - Fax:813-333-2202
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3834103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59322Medicare UPIN