Provider Demographics
NPI:1164977708
Name:LOGAN, LYNETTE
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYNETTE
Other - Middle Name:D
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 769
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-0769
Mailing Address - Country:US
Mailing Address - Phone:812-482-3020
Mailing Address - Fax:812-482-6409
Practice Address - Street 1:100 NEW STATE HWY
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-5423
Practice Address - Country:US
Practice Address - Phone:781-666-2711
Practice Address - Fax:781-666-2712
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99074547A104100000X
MA2286081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker