Provider Demographics
NPI:1982094595
Name:LOGAN, SCOTT ANDREW (PTA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANDREW
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 MICHIGAN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6053
Mailing Address - Country:US
Mailing Address - Phone:561-502-0359
Mailing Address - Fax:
Practice Address - Street 1:1416 MICHIGAN DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-6053
Practice Address - Country:US
Practice Address - Phone:561-502-0359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25056225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant