Provider Demographics
NPI:1508279860
Name:LOGOZZO, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LOGOZZO
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 1:21412 50TH AVE W
Mailing Address - Street 2:#9
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-3323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5535 S WILLIAMSON BLVD
Practice Address - Street 2:STE 774
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8311
Practice Address - Country:US
Practice Address - Phone:800-330-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3025225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist