Provider Demographics
NPI:1760888044
Name:LOGAN, SARA (COTA/L)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:WILKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1002 JIB DR
Mailing Address - Street 2:APT. 206
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-3151
Mailing Address - Country:US
Mailing Address - Phone:407-765-1592
Mailing Address - Fax:
Practice Address - Street 1:1002 JIB DR
Practice Address - Street 2:APT. 206
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3151
Practice Address - Country:US
Practice Address - Phone:407-765-1592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 13776224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL250790807680OtherDMV