Healthcare Provider Details

I. General information

NPI: 1124576525
Provider Name (Legal Business Name): LOGAN ROBINSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 CHARLEVOIX DR SE
GRAND RAPIDS MI
49546-7085
US

IV. Provider business mailing address

1143 HIGHWAY 162
CEDARVILLE AR
72932
US

V. Phone/Fax

Practice location:
  • Phone: 616-975-5092
  • Fax:
Mailing address:
  • Phone: 479-353-2679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1126
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: