MEDICARE: REBECCA LYNN LOGAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1881090678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA LYNN LOGAN

Provider Business Mailing Address
First Line	:	4310 N SPAULDING AVE # 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1237
Country	:	US
Telephone Number	:	402-440-9499
Fax Number	:

Provider Business Practice Location Address
First Line	:	4310 N SPAULDING AVE # 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1237
Country	:	US
Telephone Number	:	402-440-9499
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2014
Last Update Date	:	11/06/2014

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Directions to “ REBECCA LYNN LOGAN ” Practice Location

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