Provider Demographics
NPI:1861056558
Name:HOLLEY, LOGAN TAELOR
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:TAELOR
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 CUNNINGHAM LN S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6123
Mailing Address - Country:US
Mailing Address - Phone:503-881-1714
Mailing Address - Fax:
Practice Address - Street 1:2645 PORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0198
Practice Address - Country:US
Practice Address - Phone:503-390-5637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-28
Last Update Date:2019-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor