MEDICARE: MEGAN LOGAN, LCSW, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW8347	FL

General Provider Information

NPI Number	:	1134526510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEGAN LOGAN, LCSW, PA

Provider Business Mailing Address
First Line	:	157 HAMPTON POINT DR
Second Line	:	SUITE 1
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32092-3053
Country	:	US
Telephone Number	:	904-553-8398
Fax Number	:

Provider Business Practice Location Address
First Line	:	157 HAMPTON POINT DR
Second Line	:	SUITE 1
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32092-3053
Country	:	US
Telephone Number	:	904-553-8398
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MEGAN LOGAN
Credential	:	LCSW
Telephone Number	:	904-553-8398

Provider Enumeration Date	:	12/01/2014
Last Update Date	:	12/01/2014

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