Healthcare Provider Details

I. General information

NPI: 1629803879
Provider Name (Legal Business Name): GARRETT LOGAN OTD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16844 N 59TH AVE
GLENDALE AZ
85306-1118
US

IV. Provider business mailing address

9150 W INDIAN SCHOOL RD STE 130
PHOENIX AZ
85037-2388
US

V. Phone/Fax

Practice location:
  • Phone: 480-787-5387
  • Fax: 623-209-8822
Mailing address:
  • Phone: 480-787-5387
  • Fax: 623-232-3250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTH-009747
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: