Healthcare Provider Details

I. General information

NPI: 1194651125
Provider Name (Legal Business Name): LOGAN M RADLE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 BRIDGE ST STE 1
CHARLEVOIX MI
49720-8951
US

IV. Provider business mailing address

4048 CEDAR BLUFF DR STE 2
PETOSKEY MI
49770-8895
US

V. Phone/Fax

Practice location:
  • Phone: 231-547-0380
  • Fax:
Mailing address:
  • Phone: 231-347-5120
  • Fax: 231-347-5120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501304296
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501304296
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: