Provider Demographics
NPI:1285619346
Name:LOGAN RICHARD, PATRICIA (LCSW)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:LOGAN RICHARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06011-2828
Mailing Address - Country:US
Mailing Address - Phone:860-585-3906
Mailing Address - Fax:860-585-3907
Practice Address - Street 1:440 D N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010
Practice Address - Country:US
Practice Address - Phone:860-314-2052
Practice Address - Fax:860-314-2054
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005012104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker