Provider Demographics
NPI:1942607312
Name:CAMPBELL, LOGAN (ATC)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:LOGAN
Other - Middle Name:ANTHONY
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:737 TAMAR TRL
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-7901
Mailing Address - Country:US
Mailing Address - Phone:850-910-2051
Mailing Address - Fax:
Practice Address - Street 1:737 TAMAR TRL
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-7901
Practice Address - Country:US
Practice Address - Phone:850-910-2051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT07112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer