Provider Demographics
NPI:1912259912
Name:GILLEN, LOGAN RENEE (MA)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:RENEE
Last Name:GILLEN
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 1:1024 SHARONDALE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-1348
Mailing Address - Country:US
Mailing Address - Phone:423-390-0578
Mailing Address - Fax:
Practice Address - Street 1:1417 WARPATH DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-3333
Practice Address - Country:US
Practice Address - Phone:423-408-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor