Provider Demographics
NPI:1447717350
Name:LOGAN, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:LOGAN
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 1:3157 PINEHILLS WAY
Mailing Address - Street 2:
Mailing Address - City:MT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-0375
Mailing Address - Country:US
Mailing Address - Phone:908-342-4969
Mailing Address - Fax:
Practice Address - Street 1:284 EXECUTIVE PARK DR STE 160
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1836
Practice Address - Country:US
Practice Address - Phone:704-237-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional