Provider Demographics
NPI:1265146963
Name:MYRICK, LOGAN PAUL (PT, DPT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:PAUL
Last Name:MYRICK
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:161 PONTIAC BUSINESS CENTER DR STE 1188
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-7123
Practice Address - Country:US
Practice Address - Phone:803-708-1536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT42664225100000X
TN14748225100000X
GACP035275T225100000X
NCCP0277702T225100000X
CA304936225100000X
SCCP043916T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist