=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134023252
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOGAN CLINE LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2026
-----------------------------------------------------
Last Update Date | 10/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3228 GUN CLUB RD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33406-3093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-688-4358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 177 MULLIGAN DR
-----------------------------------------------------
City | COHUTTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30710-0010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-896-7643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW27193
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------