Provider Demographics
NPI:1417436411
Name:LOGAN, MARCELLA SUZANNE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:SUZANNE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:MARCELLA
Other - Middle Name:LOGAN
Other - Last Name:THORNBURGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:PO BOX 2639
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-2639
Mailing Address - Country:US
Mailing Address - Phone:360-791-1234
Mailing Address - Fax:
Practice Address - Street 1:4313 6TH AVE SE STE C
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1072
Practice Address - Country:US
Practice Address - Phone:360-791-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW607282771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical