Provider Demographics
NPI:1649996489
Name:LUKE, LOGAN DENISE (OTR/L)
Entity type:Individual
Prefix:MS
First Name:LOGAN
Middle Name:DENISE
Last Name:LUKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 OLD SAINT AUGUSTINE RD APT 106
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-1021
Mailing Address - Country:US
Mailing Address - Phone:904-502-1889
Mailing Address - Fax:
Practice Address - Street 1:12191 CLIPPER DR
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2237
Practice Address - Country:US
Practice Address - Phone:703-457-8648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119-009690225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist