Provider Demographics
NPI:1346241171
Name:LOGAN, LARA (PTA)
Entity Type:Individual
Prefix:MISS
First Name:LARA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 WALNUT LN # A3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1700
Mailing Address - Country:US
Mailing Address - Phone:215-849-5844
Mailing Address - Fax:
Practice Address - Street 1:919 CONESTOGA RD
Practice Address - Street 2:BUILDING 3, SUITE 114
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1352
Practice Address - Country:US
Practice Address - Phone:610-527-0178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE006543-L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant