Provider Demographics
NPI:1780727149
Name:DETWEILER, NANCY LOGAN (LCSW, LMFT)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:LOGAN
Last Name:DETWEILER
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 NW 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2722
Mailing Address - Country:US
Mailing Address - Phone:352-377-1900
Mailing Address - Fax:352-376-3872
Practice Address - Street 1:2531 NW 41ST ST
Practice Address - Street 2:SUITE C
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-7490
Practice Address - Country:US
Practice Address - Phone:352-377-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 8591041C0700X
FLMT 576106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1034OtherBLUE CROSS OF FL
FLZ1034Medicare ID - Type Unspecified