Provider Demographics
NPI:1558952168
Name:JOHNSTONE, LOGAN JAMES (COTA/L)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:JAMES
Last Name:JOHNSTONE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 NE 55TH PL
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3456
Mailing Address - Country:US
Mailing Address - Phone:859-699-0018
Mailing Address - Fax:
Practice Address - Street 1:15291 NW 60TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2459
Practice Address - Country:US
Practice Address - Phone:305-705-7702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17695224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant