Provider Demographics
NPI:1386981421
Name:LOGAN, CORBETT (LCSW-C)
Entity type:Individual
Prefix:
First Name:CORBETT
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9319 LYONSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-7140
Mailing Address - Country:US
Mailing Address - Phone:443-744-9463
Mailing Address - Fax:888-384-1972
Practice Address - Street 1:2901 DRUID PARK DR
Practice Address - Street 2:SUITE 202-C
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-8102
Practice Address - Country:US
Practice Address - Phone:443-744-9463
Practice Address - Fax:888-384-1972
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD178801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical