Provider Demographics
NPI:1619209244
Name:LOGAN, SHERRY LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:LYNN
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 1:238 RED CARNATION DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:28445-7942
Mailing Address - Country:US
Mailing Address - Phone:910-431-1032
Mailing Address - Fax:910-431-1032
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:NAVAL HOSPITAL
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-450-4159
Practice Address - Fax:910-450-4194
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-07
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7388225XP0200X, 2865M2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865M2000XHospitalsMilitary HospitalMilitary General Acute Care Hospital
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7388OtherOT LICENSE
NC7302241Medicaid