Provider Demographics
NPI:1447500723
Name:LOGAN, KATE O (LICSW)
Entity type:Individual
Prefix:
First Name:KATE
Middle Name:O
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 CORNFIELD PT
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06281-3003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:176 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-2561
Practice Address - Country:US
Practice Address - Phone:508-765-2725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT91961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040564Medicaid