Provider Demographics
NPI:1114071487
Name:LOGSDON, SHANNON L (MSPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:LOGSDON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:HAMMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4744 N COLOMA RD
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-9543
Mailing Address - Country:US
Mailing Address - Phone:269-487-6041
Mailing Address - Fax:
Practice Address - Street 1:23200 RED ARROW HWY STE A
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-7754
Practice Address - Country:US
Practice Address - Phone:269-668-5930
Practice Address - Fax:269-668-5921
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP18650002Medicare PIN