Etienne Fox Logan II

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

0732005011 Issued in VA

Practice address

1258 Holland Rd
Suffolk, VA 23434-6313

Phone

(757) 809-4771

Fax

(757) 809-4932

NPI assigned

Dec 31, 2018

Last updated

Dec 31, 2018By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Crossroads Treatment Center of Suffolk, PC

  • Methadone Clinic
  • Suffolk, VA
  • NPI 1245758135
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1546214400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1546214400000",
    "number": "1346712478",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "55 BEATTIE PL STE 810",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296012191",
            "telephone_number": "864-527-3145",
            "fax_number": "864-990-0653"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1258 HOLLAND RD",
            "city": "SUFFOLK",
            "state": "VA",
            "postal_code": "234346313",
            "telephone_number": "757-809-4771",
            "fax_number": "757-809-4932"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LOGAN",
        "first_name": "ETIENNE",
        "middle_name": "FOX",
        "name_suffix": "II",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-12-31",
        "last_updated": "2018-12-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "VA",
            "license": "0732005011",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Living Waters Therapeutic Alliance Inc
• Michael A Livoti, DPT
• Kristy Ellen Livsey, MA, LPC
• Leviticus Lofton, LCSW
• Logan and Lynn, LTD. (Denise Rae Mullins)
• Monica Logwood
• Angela Long
• Cheryl Carter Long, CLO ELO ENTERPRISES
• George Madison Long Jr., DPM
• Ramses Lamont Long, MD

• Addiction (Substance Use Disorder) Counselor in Suffolk, VA
• Providers in Suffolk, VA by specialty
• Addiction (Substance Use Disorder) Counselor in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 31, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.