Provider Demographics
NPI:1780953893
Name:LEWIS, LOGAN W JR (LMSW)
Entity type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:W
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8439 117TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1402
Mailing Address - Country:US
Mailing Address - Phone:646-879-0107
Mailing Address - Fax:718-632-1568
Practice Address - Street 1:17515 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-5503
Practice Address - Country:US
Practice Address - Phone:718-632-3275
Practice Address - Fax:718-632-1568
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073124104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker