Provider Demographics
NPI:1063892438
Name:SULLIVAN, LOGAN JON (PT)
Entity type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:JON
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18607
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85269-8607
Mailing Address - Country:US
Mailing Address - Phone:480-419-3500
Mailing Address - Fax:
Practice Address - Street 1:10115 E BELL RD
Practice Address - Street 2:ST. 101 B
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2189
Practice Address - Country:US
Practice Address - Phone:480-419-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist