Provider Demographics
NPI:1588143978
Name:BRANTLEY, LOGAN ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:ANNE
Last Name:BRANTLEY
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 1:5666 LA JOLLA BLVD PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:202-643-6573
Mailing Address - Fax:
Practice Address - Street 1:655 TOURMALINE ST APT 5H
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-1738
Practice Address - Country:US
Practice Address - Phone:919-334-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG500825681041S0200X
CA1108131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE