Provider Demographics
NPI:1508161076
Name:LOGAN, LAURIE (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:12647 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6393
Mailing Address - Country:US
Mailing Address - Phone:907-687-3202
Mailing Address - Fax:
Practice Address - Street 1:12647 OLIVE BOULEVARD
Practice Address - Street 2:SUITE 600
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:800-325-3982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK39461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical