Provider Demographics
NPI:1104692458
Name:WILBERDING, LOGAN JAMES (COTA)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:JAMES
Last Name:WILBERDING
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 E WASHINGTON AVE APT 410
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-4413
Mailing Address - Country:US
Mailing Address - Phone:954-778-7529
Mailing Address - Fax:
Practice Address - Street 1:470 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1099
Practice Address - Country:US
Practice Address - Phone:608-882-6559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7115-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant