Provider Demographics
NPI:1235703745
Name:KENNEDY, LOGAN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 BOSTIC DR. GREENVILLE, NC 27834
Mailing Address - Street 2:APT. 3710-103 C
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834
Mailing Address - Country:US
Mailing Address - Phone:910-290-3247
Mailing Address - Fax:
Practice Address - Street 1:3308 E WILSON ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-1674
Practice Address - Country:US
Practice Address - Phone:252-753-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-46152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer