MEDICARE: CASSIE W LOGAN PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT004394	GA

General Provider Information

NPI Number	:	1568751071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSIE W LOGAN PT

Provider Business Mailing Address
First Line	:	1825 PLEASANT HILL RD
Second Line	:
City	:	JASPER
State	:	GA
Zip	:	30143-3042
Country	:	US
Telephone Number	:	706-253-7232
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 PLEASANT HILL RD
Second Line	:
City	:	JASPER
State	:	GA
Zip	:	30143-3042
Country	:	US
Telephone Number	:	706-253-7232
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2011
Last Update Date	:	04/05/2011

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