Provider Demographics
NPI:1346023645
Name:LOGAN, CASEY NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:NICOLE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:NICOLE
Other - Last Name:DEMING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:6173 LANTANA LIGHT VW
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-3456
Mailing Address - Country:US
Mailing Address - Phone:813-765-1445
Mailing Address - Fax:
Practice Address - Street 1:6385 CORPORATE DR STE 307
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-5913
Practice Address - Country:US
Practice Address - Phone:719-219-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0019448225100000X
FLPT405412251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic