Provider Demographics
NPI:1992328850
Name:MONTGOMERY, LOGAN (LLPC)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 LAKE MICHIGAN DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5642
Mailing Address - Country:US
Mailing Address - Phone:231-670-1221
Mailing Address - Fax:
Practice Address - Street 1:2220 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3016
Practice Address - Country:US
Practice Address - Phone:616-277-7533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2025-07-01
Deactivation Date:2025-06-05
Deactivation Code:
Reactivation Date:2025-06-25
Provider Licenses
StateLicense IDTaxonomies
MI6451024366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional