Provider Demographics
NPI:1639770159
Name:LONG, LOGAN (COTA)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7683 SE 27TH ST STE 254
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-2804
Mailing Address - Country:US
Mailing Address - Phone:425-999-3580
Mailing Address - Fax:425-999-3122
Practice Address - Street 1:1200 112TH AVE NE STE C210
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3740
Practice Address - Country:US
Practice Address - Phone:425-999-3580
Practice Address - Fax:425-999-3122
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60925686224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60925686OtherTHERAPY ASSISTANT