Healthcare Provider Details

I. General information

NPI: 1790614519
Provider Name (Legal Business Name): JOHNATHAN LAWRENCE LOGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 RESERVOIR AVE
CRANSTON RI
02910-1729
US

IV. Provider business mailing address

480 RESERVOIR AVE
CRANSTON RI
02910-1729
US

V. Phone/Fax

Practice location:
  • Phone: 410-270-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: