Provider Demographics
NPI:1659825727
Name:TAFUR, LOGAN AVERY (OTA)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:AVERY
Last Name:TAFUR
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 CEDAR CIRCLE DR APT 210
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2814 GRAY FOX RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8422
Practice Address - Country:US
Practice Address - Phone:704-821-0568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-06
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 13360224Z00000X
NC16032224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant