Provider Demographics
NPI:1568461168
Name:LOGAN, ANN (PHD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-6723
Mailing Address - Country:US
Mailing Address - Phone:304-322-9922
Mailing Address - Fax:
Practice Address - Street 1:823 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-6723
Practice Address - Country:US
Practice Address - Phone:304-322-9922
Practice Address - Fax:831-708-2797
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV726103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165178002Medicaid
WVP10649Medicare UPIN
WVCP22891192Medicare ID - Type Unspecified