MEDICARE: LAPEARL LOGAN WINFREY PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	5852	OH

General Provider Information

NPI Number	:	1730180647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAPEARL LOGAN WINFREY PH.D

Provider Business Mailing Address
First Line	:	PO BOX 341648
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45434-1648
Country	:	US
Telephone Number	:	937-254-9210
Fax Number	:	937-254-9267

Provider Business Practice Location Address
First Line	:	1255 N FAIRFIELD RD STE 201
Second Line	:
City	:	BEAVERCREEK
State	:	OH
Zip	:	45432-2651
Country	:	US
Telephone Number	:	937-254-9210
Fax Number	:	937-254-9267

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	06/22/2015

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