Healthcare Provider Details

I. General information

NPI: 1245440254
Provider Name (Legal Business Name): MARY CALLAWAY LOGAN LPC, M.DIV., FELLOW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 PONCE DE LEON AVE NE
ATLANTA GA
30306-4602
US

IV. Provider business mailing address

1200 PONCE DE LEON AVE NE
ATLANTA GA
30306-4602
US

V. Phone/Fax

Practice location:
  • Phone: 404-931-6395
  • Fax:
Mailing address:
  • Phone: 404-931-6395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number000758
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: