Healthcare Provider Details

I. General information

NPI: 1306474549
Provider Name (Legal Business Name): MARIAH LYN LOGAN LPC,LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 OLIVE BLVD STE 176
CREVE COEUR MO
63141-7147
US

IV. Provider business mailing address

207 GLEN MEADOW RD
FRANKLIN MA
02038-1341
US

V. Phone/Fax

Practice location:
  • Phone: 618-972-1568
  • Fax: 618-205-3561
Mailing address:
  • Phone: 314-541-4618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2023048395
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.014691
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: