Provider Demographics
NPI:1972367324
Name:DEBEATHAM, LOGAN A (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:A
Last Name:DEBEATHAM
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E WEST HWY APT 329
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-2368
Mailing Address - Country:US
Mailing Address - Phone:860-983-1121
Mailing Address - Fax:
Practice Address - Street 1:1331 H ST NW STE 200
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-4706
Practice Address - Country:US
Practice Address - Phone:860-983-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10155225X00000X
DCOT210002228225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist