Provider Demographics
NPI:1699015412
Name:LOGAN, LOI L (LSW)
Entity Type:Individual
Prefix:
First Name:LOI
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 BRIDGEPORT PL
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-2624
Mailing Address - Country:US
Mailing Address - Phone:224-399-6646
Mailing Address - Fax:630-787-0484
Practice Address - Street 1:609 BRIDGEPORT PL
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-2624
Practice Address - Country:US
Practice Address - Phone:224-399-6646
Practice Address - Fax:630-787-0484
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150014033104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker