Healthcare Provider Details

I. General information

NPI: 1518652049
Provider Name (Legal Business Name): HEATH AVERY LOGUE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N CAROL MALONE BLVD
GRAYSON KY
41143-1566
US

IV. Provider business mailing address

336 29TH ST STE 203
ASHLAND KY
41101-1932
US

V. Phone/Fax

Practice location:
  • Phone: 606-225-8200
  • Fax: 888-606-7354
Mailing address:
  • Phone: 606-225-8200
  • Fax: 888-606-7354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW00001729
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: