Provider Demographics
NPI:1396200119
Name:COOK, LOGAN BRYAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:BRYAN
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36081-4063
Mailing Address - Country:US
Mailing Address - Phone:334-722-0622
Mailing Address - Fax:
Practice Address - Street 1:103 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36081-4063
Practice Address - Country:US
Practice Address - Phone:334-722-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer