Provider Demographics
NPI:1669767935
Name:LOGAN, TINA MARIE (OT)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20458 MIDWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3811
Mailing Address - Country:US
Mailing Address - Phone:248-469-9856
Mailing Address - Fax:
Practice Address - Street 1:20458 MIDWAY AVE
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3811
Practice Address - Country:US
Practice Address - Phone:248-469-9856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14109225X00000X
MI4704290093163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist