Provider Demographics
NPI:1790256279
Name:LEWIS, LOGAN (LMSW, LMFT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LMSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-2165
Mailing Address - Country:US
Mailing Address - Phone:315-806-6779
Mailing Address - Fax:
Practice Address - Street 1:1045 JAMES ST STE 100
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2758
Practice Address - Country:US
Practice Address - Phone:315-472-4471
Practice Address - Fax:315-472-1759
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105136-1104100000X
NY001662106H00000X
NY0961561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist