Provider Demographics
NPI:1861037301
Name:HALL, LOGAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S JUNIPER ST # 621
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-2703
Mailing Address - Country:US
Mailing Address - Phone:215-458-2036
Mailing Address - Fax:215-798-9581
Practice Address - Street 1:100 S JUNIPER ST # 621
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-2703
Practice Address - Country:US
Practice Address - Phone:215-458-2036
Practice Address - Fax:215-798-9581
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACW0210066OtherLICENSED CLINICAL SOCIAL WORKER (LCSW)