Provider Demographics
NPI:1700058005
Name:LOGAN, JULIE ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
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 1:1740 S BELL SCHOOL RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61016-9388
Mailing Address - Country:US
Mailing Address - Phone:815-316-2621
Mailing Address - Fax:800-493-9260
Practice Address - Street 1:1740 S BELL SCHOOL RD STE B
Practice Address - Street 2:
Practice Address - City:CHERRY VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61016-9388
Practice Address - Country:US
Practice Address - Phone:815-316-2621
Practice Address - Fax:800-493-9260
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490114211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212696Medicare PIN