Provider Demographics
NPI:1831412915
Name:LOGAN, VIRGINIA WELLS (MA)
Entity type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:WELLS
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 GOOSENECK BEND RD
Mailing Address - Street 2:
Mailing Address - City:WEYBRIDGE
Mailing Address - State:VT
Mailing Address - Zip Code:05753-9635
Mailing Address - Country:US
Mailing Address - Phone:802-989-3743
Mailing Address - Fax:
Practice Address - Street 1:64 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1426
Practice Address - Country:US
Practice Address - Phone:802-989-3743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000348103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist