Provider Demographics
NPI:1770294936
Name:LOGAN, CARLTON JOSHUA (ATC)
Entity type:Individual
Prefix:
First Name:CARLTON
Middle Name:JOSHUA
Last Name:LOGAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1957 MARY JO WAY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-9386
Mailing Address - Country:US
Mailing Address - Phone:251-423-2408
Mailing Address - Fax:
Practice Address - Street 1:2065 AIRPORT BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5930
Practice Address - Country:US
Practice Address - Phone:850-477-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL67752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer