Provider Demographics
NPI:1548322423
Name:LOGAN GREEN, PH.D.
Entity type:Organization
Organization Name:LOGAN GREEN, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-632-1296
Mailing Address - Street 1:494 MAIN ST
Mailing Address - Street 2:APT 1
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2040
Mailing Address - Country:US
Mailing Address - Phone:860-632-1296
Mailing Address - Fax:
Practice Address - Street 1:494 MAIN ST
Practice Address - Street 2:APT 1
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2040
Practice Address - Country:US
Practice Address - Phone:860-632-1296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT852103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty