Provider Demographics
NPI:1194113852
Name:LOGAN, RACHEL (LCSW)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 GREEN MOUNT CROSSING DR STE 407
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7287
Mailing Address - Country:US
Mailing Address - Phone:618-310-0422
Mailing Address - Fax:
Practice Address - Street 1:10850 LINCOLN TRAIL
Practice Address - Street 2:SUITE 16 #3
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:618-310-0422
Practice Address - Fax:618-226-5179
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0172241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical