1417436411 NPI number — MARCELLA SUZANNE LOGAN MSW, LICSW

Table of content: MARCELLA SUZANNE LOGAN MSW, LICSW (NPI 1417436411)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417436411 NPI number — MARCELLA SUZANNE LOGAN MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
LOGAN

Provider First Name:
MARCELLA

Provider Middle Name:
SUZANNE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
MSW, LICSW

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
THORNBURGH

Provider Other First Name:
MARCELLA

Provider Other Middle Name:
LOGAN

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:
MSW, LICSW

Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417436411

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
08/09/2018

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2639

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
OLYMPIA

Provider Business Mailing Address State Name:
WA

Provider Business Mailing Address Postal Code:
98507-2639

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
360-791-1234

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4313 6TH AVE SE STE C

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
LACEY

Provider Business Practice Location Address State Name:
WA

Provider Business Practice Location Address Postal Code:
98503-1072

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
360-791-1234

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
08/09/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 1041C0700X , with the licence number: LW60728277 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .