Provider Demographics
NPI:1821377854
Name:LOGAN, GAYLE VENCE (MA,LMSW,LPC)
Entity Type:Individual
Prefix:MS
First Name:GAYLE
Middle Name:VENCE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MA,LMSW,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449 GOLF RD STE 14
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1475
Mailing Address - Country:US
Mailing Address - Phone:215-477-3103
Mailing Address - Fax:215-477-3104
Practice Address - Street 1:2449 GOLF RD STE 14
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1475
Practice Address - Country:US
Practice Address - Phone:215-477-3103
Practice Address - Fax:215-477-3104
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005429101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional