Provider Demographics
NPI:1912134297
Name:LOGAN, ANNETTE (AT)
Entity Type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:AT
Other - Prefix:MS
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:25 LAWNCREST RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1512
Mailing Address - Country:US
Mailing Address - Phone:203-479-8066
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-479-8066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)