Provider Demographics
NPI:1457819807
Name:HATLEY, LOGAN (LAT, ATC, CPT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:HATLEY
Suffix:
Gender:M
Credentials:LAT, ATC, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18525 ROLLINGDALE LN
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7862
Mailing Address - Country:US
Mailing Address - Phone:704-776-3781
Mailing Address - Fax:
Practice Address - Street 1:3 GRIER AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29409-1004
Practice Address - Country:US
Practice Address - Phone:843-953-6867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAT030922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAT03092OtherSOUTH CAROLINA ATHLETIC TRAINING LICENSURE
2000042328OtherBOC CERTIFICATION