Provider Demographics
NPI:1356644819
Name:WILLIAMS, LOGAN ROY (LMP)
Entity type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:ROY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S MANUEL LN
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-9248
Mailing Address - Country:US
Mailing Address - Phone:509-952-8036
Mailing Address - Fax:
Practice Address - Street 1:9 E 1ST AVE
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-1400
Practice Address - Country:US
Practice Address - Phone:509-697-4838
Practice Address - Fax:509-697-6132
Is Sole Proprietor?:No
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60108104225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist