Provider Demographics
NPI:1629803879
Name:LOGAN, GARRETT (OTD)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9150 W INDIAN SCHOOL RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-2388
Mailing Address - Country:US
Mailing Address - Phone:480-787-5387
Mailing Address - Fax:623-232-3250
Practice Address - Street 1:16844 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1118
Practice Address - Country:US
Practice Address - Phone:480-787-5387
Practice Address - Fax:623-209-8822
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-009747225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty