Individual
BREANNA LOGAN CLUBB
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
522 E MAIN ST, MASCOUTAH, IL 62258-2240
(618) 566-0313
Mailing address
605 S BENTON ST, NEW ATHENS, IL 62264-1608
(618) 550-9969
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
—
Other
Enumeration date
09/12/2022
Last updated
09/12/2022
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