Provider Demographics
NPI:1235495466
Name:LOGAN, RYAN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 TAVERN WAY
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2856
Mailing Address - Country:US
Mailing Address - Phone:631-678-8816
Mailing Address - Fax:
Practice Address - Street 1:23 TAVERN WAY
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2856
Practice Address - Country:US
Practice Address - Phone:631-678-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085124-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker