Provider Demographics
NPI:1346865110
Name:TAYLOR, LOGAN NICHOLAS (DPT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:NICHOLAS
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1908
Mailing Address - Country:US
Mailing Address - Phone:816-429-5199
Mailing Address - Fax:816-429-7129
Practice Address - Street 1:102 S FORREST AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1908
Practice Address - Country:US
Practice Address - Phone:816-429-5199
Practice Address - Fax:816-429-7129
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020015509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist