Provider Demographics
NPI:1992239552
Name:LOGAN, NICOLE RENEE (LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 BASILDON RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7140
Mailing Address - Country:US
Mailing Address - Phone:843-593-2274
Mailing Address - Fax:
Practice Address - Street 1:887 JOHNNIE DODDS BLVD STE 217
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3154
Practice Address - Country:US
Practice Address - Phone:843-593-2274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6488101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor