MEDICARE: CAMILLE LOGAN

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1306079462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLE LOGAN

Provider Business Mailing Address
First Line	:	7406 CHAPEL HILL ROAD
Second Line	:	STE F
City	:	RALEIGH
State	:	NC
Zip	:	27607
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7406 CHAPEL HILL RD
Second Line	:	STE F
City	:	RALEIGH
State	:	NC
Zip	:	27607-5077
Country	:	US
Telephone Number	:	941-219-5948
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2009
Last Update Date	:	03/31/2015

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Directions to “ CAMILLE LOGAN ” Practice Location

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