Provider Demographics
NPI:1083508394
Name:WAHL, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:WAHL
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 1:213 LODGE POLE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-4800
Mailing Address - Country:US
Mailing Address - Phone:541-215-5923
Mailing Address - Fax:
Practice Address - Street 1:2463 E GALA ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5209
Practice Address - Country:US
Practice Address - Phone:208-955-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist