Provider Demographics
NPI:1508339961
Name:MASSINGILL, BEAU LOGAN (DPT)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:LOGAN
Last Name:MASSINGILL
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 1:510 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-2004
Mailing Address - Country:US
Mailing Address - Phone:734-625-6903
Mailing Address - Fax:
Practice Address - Street 1:1291 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3368
Practice Address - Country:US
Practice Address - Phone:734-243-0300
Practice Address - Fax:734-243-3066
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MI5501302274225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer