Provider Demographics
NPI:1912728270
Name:LOGAN, DIASHANNA YVETTE
Entity type:Individual
Prefix:
First Name:DIASHANNA
Middle Name:YVETTE
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 1:537 W SUGAR CREEK RD STE 203
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-6102
Mailing Address - Country:US
Mailing Address - Phone:980-875-9473
Mailing Address - Fax:704-595-7155
Practice Address - Street 1:537 W SUGAR CREEK RD STE 203
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-6102
Practice Address - Country:US
Practice Address - Phone:980-875-9473
Practice Address - Fax:704-595-7155
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20359101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health