Healthcare Provider Details

I. General information

NPI: 1861101610
Provider Name (Legal Business Name): ANNMARIE JANE LOGAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 MONTAUK HWY
MASTIC NY
11950-2917
US

IV. Provider business mailing address

105 E MAIN ST
SMITHTOWN NY
11787-2858
US

V. Phone/Fax

Practice location:
  • Phone: 631-924-3741
  • Fax: 631-924-2413
Mailing address:
  • Phone: 631-519-8869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number120931-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: