Healthcare Provider Details

I. General information

NPI: 1477478071
Provider Name (Legal Business Name): LOGAN WILLIAM TEWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 LAKEVIEW PKWY STE 150
VERNON HILLS IL
60061-1839
US

IV. Provider business mailing address

1325 LINCOLN ST
NORTH CHICAGO IL
60064-1422
US

V. Phone/Fax

Practice location:
  • Phone: 877-486-4140
  • Fax:
Mailing address:
  • Phone: 773-706-1877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-462062
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: