Provider Demographics
NPI:1700198785
Name:LOGAN, RACQUEL (MT)
Entity Type:Individual
Prefix:
First Name:RACQUEL
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:RACQUEL
Other - Middle Name:
Other - Last Name:SIDHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1273 LORELEI CT
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1716
Mailing Address - Country:US
Mailing Address - Phone:408-313-6909
Mailing Address - Fax:
Practice Address - Street 1:653 E CAMPBELL AVE STE 5
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2143
Practice Address - Country:US
Practice Address - Phone:408-313-6909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPENDING225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist