Healthcare Provider Details

I. General information

NPI: 1316199961
Provider Name (Legal Business Name): MELISSA KAY LOGAN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 INTERSTATE 630 EXIT 7
LITTLE ROCK AR
72205-7202
US

IV. Provider business mailing address

PO BOX 1663
HEBER SPRINGS AR
72543-1663
US

V. Phone/Fax

Practice location:
  • Phone: 501-202-7598
  • Fax:
Mailing address:
  • Phone: 501-362-2339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3071
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: