Provider Demographics
NPI:1952988651
Name:LOGAN, ELIZABETH LEANNE (PTA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LEANNE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 CASA GRANDE ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79118-2024
Mailing Address - Country:US
Mailing Address - Phone:806-690-7041
Mailing Address - Fax:
Practice Address - Street 1:1242 CASA GRANDE ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79118-2024
Practice Address - Country:US
Practice Address - Phone:806-690-7041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2006573225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant