MEDICARE: LOGAN GILLEN LOVE MA, LMFT, PHD

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	101YM0800X	Mental Health Counselor	1116	TN
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1912259912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN GILLEN LOVE MA, LMFT, PHD

Provider Business Mailing Address
First Line	:	2050 LEE HWY
Second Line	:
City	:	BRISTOL
State	:	VA
Zip	:	24201-1626
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 MEADOW VIEW RD
Second Line	:
City	:	BRISTOL
State	:	TN
Zip	:	37620-1661
Country	:	US
Telephone Number	:	423-797-4555
Fax Number	:

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

Provider Enumeration Date	:	10/15/2012
Last Update Date	:	01/29/2025

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