MEDICARE: LOGAN BEVERLY OTD, OTR

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	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1073214789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN BEVERLY OTD, OTR

Provider Business Mailing Address
First Line	:	218 FM 1791 RD
Second Line	:
City	:	HUNTSVILLE
State	:	TX
Zip	:	77340-2009
Country	:	US
Telephone Number	:	936-661-5364
Fax Number	:

Provider Business Practice Location Address
First Line	:	21325 EVA ST
Second Line	:
City	:	MONTGOMERY
State	:	TX
Zip	:	77356-1967
Country	:	US
Telephone Number	:	936-463-1701
Fax Number	:	346-202-0123

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

Provider Enumeration Date	:	03/10/2023
Last Update Date	:	09/23/2024

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