Healthcare Provider Details

I. General information

NPI: 1912259912
Provider Name (Legal Business Name): LOGAN GILLEN LOVE MA, LMFT, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LOGAN RENEE GILLEN

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MEADOW VIEW RD
BRISTOL TN
37620-1661
US

IV. Provider business mailing address

2050 LEE HWY
BRISTOL VA
24201-1626
US

V. Phone/Fax

Practice location:
  • Phone: 423-797-4555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1116
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: