Provider Demographics
NPI:1518504323
Name:LOGAN, DANIELLE COLSTON (OTR/L)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:COLSTON
Last Name:LOGAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-9595
Mailing Address - Country:US
Mailing Address - Phone:770-617-2598
Mailing Address - Fax:
Practice Address - Street 1:4900 IVEY RD NW STE 1720
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4101
Practice Address - Country:US
Practice Address - Phone:770-917-5737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-30
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007594225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist