Healthcare Provider Details

I. General information

NPI: 1699015412
Provider Name (Legal Business Name): LOI L LOGAN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2013
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 BRIDGEPORT PL
WHEELING IL
60090-2624
US

IV. Provider business mailing address

609 BRIDGEPORT PL
WHEELING IL
60090-2624
US

V. Phone/Fax

Practice location:
  • Phone: 224-399-6646
  • Fax: 630-787-0484
Mailing address:
  • Phone: 224-399-6646
  • Fax: 630-787-0484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150014033
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: