Healthcare Provider Details

I. General information

NPI: 1780953893
Provider Name (Legal Business Name): LOGAN W. LEWIS JR. LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17515 ROCKAWAY BLVD
JAMAICA NY
11434-5503
US

IV. Provider business mailing address

8439 117TH ST
RICHMOND HILL NY
11418-1402
US

V. Phone/Fax

Practice location:
  • Phone: 718-632-3275
  • Fax: 718-632-1568
Mailing address:
  • Phone: 646-879-0107
  • Fax: 718-632-1568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number073124
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: