Provider Demographics
NPI:1770140949
Name:SPICER, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:SPICER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3123 S SHIELDS AVE APT BSMT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4967
Mailing Address - Country:US
Mailing Address - Phone:317-619-9225
Mailing Address - Fax:
Practice Address - Street 1:9855 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-2758
Practice Address - Country:US
Practice Address - Phone:708-681-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE101YM0800X
IL180015338101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health