Provider Demographics
NPI:1477015725
Name:LOGAN, DEIDRA A (OT, OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:A
Last Name:LOGAN
Suffix:
Gender:F
Credentials:OT, OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 MCGILVRA BLVD E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-3123
Mailing Address - Country:US
Mailing Address - Phone:818-813-2216
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:818-813-2216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT61613593225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOT61613593OtherWASHINGTON STATE DEPARTMENT OF HEALTH
522754OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY