Healthcare Provider Details

I. General information

NPI: 1881738904
Provider Name (Legal Business Name): LOGAN PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 N 400 E SUITE C
LOGAN UT
84341-1788
US

IV. Provider business mailing address

PO BOX 6518 2310 NORTH 400 EAST SUITE C
NORTH LOGAN UT
84341-6518
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-5200
  • Fax: 435-752-5228
Mailing address:
  • Phone: 435-752-5200
  • Fax: 435-752-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1162582401
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier326689687024-N0654
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: SUSAN DOUCETTE
Title or Position: OWNER
Credential: PT
Phone: 435-752-5200