Provider Demographics
NPI:1326561325
Name:LOGAN, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:LOGAN
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 1:557 EASTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27239-7639
Mailing Address - Country:US
Mailing Address - Phone:336-590-3904
Mailing Address - Fax:
Practice Address - Street 1:106 MOUNT VISTA RD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:NC
Practice Address - Zip Code:27239-8793
Practice Address - Country:US
Practice Address - Phone:336-859-2181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11008224Z00000X
224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant