Provider Demographics
NPI:1215634316
Name:SMITH, LOGAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44191 PLYMOUTH OAKS BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2538
Mailing Address - Country:US
Mailing Address - Phone:810-853-0086
Mailing Address - Fax:
Practice Address - Street 1:44191 PLYMOUTH OAKS BLVD STE 800
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2538
Practice Address - Country:US
Practice Address - Phone:734-463-3007
Practice Address - Fax:734-203-0901
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501302333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist