MEDICARE: LOGAN OLIVIA DECOURSEY

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	106S00000X	Behavior Technician		CA

General Provider Information

NPI Number	:	1144188178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN OLIVIA DECOURSEY

Provider Business Mailing Address
First Line	:	996 ROYAL MARCO WAY
Second Line	:
City	:	MARCO ISLAND
State	:	FL
Zip	:	34145-1829
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12660 RIVERSIDE DR
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-3429
Country	:	US
Telephone Number	:	818-614-3362
Fax Number	:

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

Provider Enumeration Date	:	01/09/2026
Last Update Date	:	01/09/2026

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Directions to “ LOGAN OLIVIA DECOURSEY ” Practice Location

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