Provider Demographics
NPI:1760932263
Name:POPP, LOGAN (OT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:POPP
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9480 PRIORITY WAY WEST DR.
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 LAFEYETTE PARKWAY
Practice Address - Street 2:
Practice Address - City:FLOYDS KNOBS
Practice Address - State:IN
Practice Address - Zip Code:47119
Practice Address - Country:US
Practice Address - Phone:812-923-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006147A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist