Provider Demographics
NPI:1255887105
Name:SEBASTIAN, LOGAN (DPT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MADISON ST STE LL2
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-1764
Mailing Address - Country:US
Mailing Address - Phone:703-299-6688
Mailing Address - Fax:
Practice Address - Street 1:209 MADISON ST STE LL2
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1764
Practice Address - Country:US
Practice Address - Phone:703-299-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist