Provider Demographics
NPI:1215089917
Name:LOGAN, GEORGIANA (LICSW)
Entity type:Individual
Prefix:
First Name:GEORGIANA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 BEACON STREET
Mailing Address - Street 2:
Mailing Address - City:NEWTON CENTRE
Mailing Address - State:MA
Mailing Address - Zip Code:02459
Mailing Address - Country:US
Mailing Address - Phone:617-306-3646
Mailing Address - Fax:
Practice Address - Street 1:1601 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-425-2040
Practice Address - Fax:617-425-2043
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
47320104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker