Provider Demographics
NPI:1316393598
Name:LOGUE, RYAN (LCPC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LOGUE
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5462 TILTED STONE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2430
Mailing Address - Country:US
Mailing Address - Phone:240-481-5164
Mailing Address - Fax:
Practice Address - Street 1:5462 TILTED STONE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2430
Practice Address - Country:US
Practice Address - Phone:240-481-5164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5991101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health