Healthcare Provider Details

I. General information

NPI: 1255887105
Provider Name (Legal Business Name): LOGAN SEBASTIAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MADISON ST STE LL2
ALEXANDRIA VA
22314-1764
US

IV. Provider business mailing address

209 MADISON ST STE LL2
ALEXANDRIA VA
22314-1764
US

V. Phone/Fax

Practice location:
  • Phone: 703-299-6688
  • Fax:
Mailing address:
  • Phone: 703-299-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305211185
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: