Provider Demographics
NPI:1174245872
Name:BREITWEISER, LOGAN DENZIL
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:DENZIL
Last Name:BREITWEISER
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 1:2801 E YESLER WAY APT 31
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-6576
Mailing Address - Country:US
Mailing Address - Phone:720-989-8295
Mailing Address - Fax:
Practice Address - Street 1:123 NW 36TH ST STE 210
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4959
Practice Address - Country:US
Practice Address - Phone:206-402-5767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
WAMC61463215101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program