Provider Demographics
NPI:1972583763
Name:LOGUE, MARY BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY BETH
Middle Name:
Last Name:LOGUE
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:PSC 482 BOX 175
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362
Mailing Address - Country:US
Mailing Address - Phone:81611-634-2740
Mailing Address - Fax:81611-634-2708
Practice Address - Street 1:PSC 482 BOX 175
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362
Practice Address - Country:US
Practice Address - Phone:81611-634-2740
Practice Address - Fax:81611-634-2708
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK812103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent