Provider Demographics
NPI:1245440254
Name:LOGAN, MARY CALLAWAY (LPC, MDIV, FELLOW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:CALLAWAY
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LPC, MDIV, FELLOW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 PONCE DE LEON AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4602
Mailing Address - Country:US
Mailing Address - Phone:404-931-6395
Mailing Address - Fax:
Practice Address - Street 1:1200 PONCE DE LEON AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4602
Practice Address - Country:US
Practice Address - Phone:404-931-6395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000758101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000758OtherLICENSED PROFESSIONAL COU