MEDICARE: MARY C LOGALBO PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209.011822	IL

General Provider Information

NPI Number	:	1427451509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY C LOGALBO PMHNP-BC

Provider Business Mailing Address
First Line	:	748 VERSAILLES PKWY
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-6019
Country	:	US
Telephone Number	:	630-392-3431
Fax Number	:

Provider Business Practice Location Address
First Line	:	2124 OGDEN AVE STE 301
Second Line	:
City	:	AURORA
State	:	IL
Zip	:	60504-7542
Country	:	US
Telephone Number	:	630-392-3431
Fax Number	:

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

Provider Enumeration Date	:	10/02/2014
Last Update Date	:	12/21/2023

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