=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912766916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOGAN REDDY DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2024
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5730 RUDDELL RD SE STE A
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-338-3901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7310 ELGAR ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22151-3132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-470-0505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT61231005
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 2305211938
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------