Provider Demographics
NPI:1003272543
Name:WADDELL, LOGAN STEWART (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:STEWART
Last Name:WADDELL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 ROYALWOODS CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45244-3655
Mailing Address - Country:US
Mailing Address - Phone:513-368-5212
Mailing Address - Fax:
Practice Address - Street 1:8135 BEECHMONT AVE
Practice Address - Street 2:WEST 269
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-6138
Practice Address - Country:US
Practice Address - Phone:513-368-5212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT015171225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist