Healthcare Provider Details

I. General information

NPI: 1972030823
Provider Name (Legal Business Name): LOGAN TATE SUTHERLAND LSW, MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E DUBLIN GRANVILLE RD
WORTHINGTON OH
43085-3192
US

IV. Provider business mailing address

445 E DUBLIN GRANVILLE RD
WORTHINGTON OH
43085-3192
US

V. Phone/Fax

Practice location:
  • Phone: 614-436-7837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1901967-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: