Provider Demographics
NPI:1851689079
Name:LOGAN, RACHEL ANNETTE (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNETTE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3964 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565-1104
Mailing Address - Country:US
Mailing Address - Phone:850-741-6715
Mailing Address - Fax:850-204-0489
Practice Address - Street 1:3964 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:FL
Practice Address - Zip Code:32565-1104
Practice Address - Country:US
Practice Address - Phone:850-741-6715
Practice Address - Fax:850-204-0489
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005260225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist