Provider Demographics
NPI:1356594634
Name:LOGAN, TOMIKO (LCSW)
Entity type:Individual
Prefix:MRS
First Name:TOMIKO
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 HOWELL COURT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-7962
Mailing Address - Country:US
Mailing Address - Phone:240-547-7894
Mailing Address - Fax:
Practice Address - Street 1:1107 HOWELL CT
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-7962
Practice Address - Country:US
Practice Address - Phone:240-547-7894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0040381041C0700X
GA7546741041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool