Provider Demographics
NPI:1154292894
Name:ANDERSON, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:ANDERSON
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 1:461 34TH ST SW
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2215
Mailing Address - Country:US
Mailing Address - Phone:701-630-6100
Mailing Address - Fax:
Practice Address - Street 1:461 34TH ST SW
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2215
Practice Address - Country:US
Practice Address - Phone:701-630-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health