Provider Demographics
NPI:1861375149
Name:LOGAN, TRACEE
Entity type:Individual
Prefix:
First Name:TRACEE
Middle Name:
Last Name:LOGAN
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 1:2846 KEEN DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-2428
Mailing Address - Country:US
Mailing Address - Phone:619-717-0347
Mailing Address - Fax:
Practice Address - Street 1:2141 PALOMAR AIRPORT RD STE 350
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1451
Practice Address - Country:US
Practice Address - Phone:619-299-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-25
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician