Provider Demographics
NPI:1124372404
Name:RICHARDSON, LOGAN THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:THOMAS
Last Name:RICHARDSON
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 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:996 NW CIRCLE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1485
Practice Address - Country:US
Practice Address - Phone:541-757-0878
Practice Address - Fax:541-757-0879
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500652534Medicaid
OR500652534Medicaid