Provider Demographics
NPI:1497315196
Name:SMITH, LOGAN M (PT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4914
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1775 ALYSHEBA WAY STE 10
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2479
Practice Address - Country:US
Practice Address - Phone:859-260-4540
Practice Address - Fax:859-260-4545
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY007579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist