Provider Demographics
NPI:1780777961
Name:ELLINGTON-HARRISON, LOGAN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LOGAN
Middle Name:
Last Name:ELLINGTON-HARRISON
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 1:116 DUNBAR DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8018
Mailing Address - Country:US
Mailing Address - Phone:757-537-3414
Mailing Address - Fax:
Practice Address - Street 1:135 S SARATOGA ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-5322
Practice Address - Country:US
Practice Address - Phone:757-942-1985
Practice Address - Fax:757-925-2213
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040058521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010105439Medicaid
VA010105366Medicaid
VA0101079519Medicaid