Provider Demographics
NPI:1578987509
Name:LOGAN, TRACY ANN (COTA)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ANN
Last Name:LOGAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 AUTUMNWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4335
Mailing Address - Country:US
Mailing Address - Phone:386-290-6310
Mailing Address - Fax:
Practice Address - Street 1:25 AUTUMNWOOD TRL
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4335
Practice Address - Country:US
Practice Address - Phone:386-290-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13006224Z00000X
TX212209224Z00000X
CA2672224Z00000X
IA001017224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant