Provider Demographics
NPI:1881738904
Name:LOGAN PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:LOGAN PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUCETTE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:435-752-5200
Mailing Address - Street 1:PO BOX 6518
Mailing Address - Street 2:2310 NORTH 400 EAST SUITE C
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-6518
Mailing Address - Country:US
Mailing Address - Phone:435-752-5200
Mailing Address - Fax:435-752-5228
Practice Address - Street 1:2310 N 400 E
Practice Address - Street 2:SUITE C
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1788
Practice Address - Country:US
Practice Address - Phone:435-752-5200
Practice Address - Fax:435-752-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1162582401261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT326689687024-N0654Medicaid
UT326689687024-N0654Medicaid