Healthcare Provider Details

I. General information

NPI: 1316756307
Provider Name (Legal Business Name): LOGAN MICHAEL BEN-EZRA PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 POTOMAC BRANCH DR STE 300
WOODBRIDGE VA
22191-3337
US

IV. Provider business mailing address

28866 KENDALLWOOD DR
FARMINGTON HILLS MI
48334-2638
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-1112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.027620
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: