Provider Demographics
NPI:1407557234
Name:LOGAN, CALEB
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:LOGAN
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 1:6416 CUTCANE RD
Mailing Address - Street 2:
Mailing Address - City:MINERAL BLUFF
Mailing Address - State:GA
Mailing Address - Zip Code:30559-3078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 INDUSTRIAL DR.
Practice Address - Street 2:
Practice Address - City:DUCKTOWN
Practice Address - State:TN
Practice Address - Zip Code:37326
Practice Address - Country:US
Practice Address - Phone:423-496-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2839224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant