Healthcare Provider Details

I. General information

NPI: 1265146963
Provider Name (Legal Business Name): LOGAN PAUL MYRICK PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 GRANT AVE STE 100
LOVELAND CO
80538-8433
US

IV. Provider business mailing address

3880 GRANT AVE STE 100
LOVELAND CO
80538-8433
US

V. Phone/Fax

Practice location:
  • Phone: 970-663-7780
  • Fax:
Mailing address:
  • Phone: 970-663-7780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP0277702T
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14748
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP053159T
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT42664
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP035275T
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304936
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP043916T
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: