Provider Demographics
NPI:1073089579
Name:LOGAN, SCOTT (PT)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 GRAYSTONE RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-8863
Mailing Address - Country:US
Mailing Address - Phone:269-767-4710
Mailing Address - Fax:
Practice Address - Street 1:165 WASHINGTON AVE N
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-2929
Practice Address - Country:US
Practice Address - Phone:269-245-3676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist