Provider Demographics
NPI:1831810191
Name:LOGAN, LAURA L (LMT, CNA)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:F
Credentials:LMT, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-1016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2307 BELLMORE AVE
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5651
Practice Address - Country:US
Practice Address - Phone:516-457-6421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12888225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8OtherMASSAGE