Provider Demographics
NPI:1124576525
Name:ROBINSON, LOGAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:ROBINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 HIGHWAY 162
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72932
Mailing Address - Country:US
Mailing Address - Phone:479-353-2679
Mailing Address - Fax:
Practice Address - Street 1:2900 CHARLEVOIX DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7085
Practice Address - Country:US
Practice Address - Phone:616-975-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1126224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant