Provider Demographics
NPI:1598544116
Name:WILZ, LOGAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:WILZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 S STATE ST APT 405
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2217
Mailing Address - Country:US
Mailing Address - Phone:920-538-0122
Mailing Address - Fax:
Practice Address - Street 1:910 SKOKIE BLVD STE 215
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-4033
Practice Address - Country:US
Practice Address - Phone:847-480-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38377101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)