Provider Demographics
NPI:1073654778
Name:LOGAN, TINA M (RPT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:LOGAN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:2555 HIGHWAY 78 E
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-3433
Practice Address - Country:US
Practice Address - Phone:205-385-7919
Practice Address - Fax:205-803-6458
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH 3715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL71-0945220OtherEMPLOYER TAX ID
AL63-1196634OtherEMPLOYER TAX ID
AL71-0945220OtherEMPLOYER TAX ID
AL63-1196634OtherEMPLOYER TAX ID