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General NPI Number Information
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NPI Number | 1316756307
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Entity Type | Individual
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Provider Name | LOGAN MICHAEL BEN-EZRA PT, DPT, CSCS
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Gender | Male
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Dates
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Enumeration Date | 01/03/2025
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Last Update Date | 01/03/2025
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Provider Practice Location Address
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Address Line | 14605 POTOMAC BRANCH DR STE 300
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3337
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Country | US
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Telephone | 703-490-1112
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Fax |
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Provider Business Mailing Address
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Address Line | 28866 KENDALLWOOD DR
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City | FARMINGTON HILLS
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State | MI
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Zip | 48334-2638
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070.027620
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License Number State | IL
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