Provider Demographics
NPI:1487138434
Name:GAILITIS, LOGAN L (ATS)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:L
Last Name:GAILITIS
Suffix:
Gender:M
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CHERRYFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-2404
Mailing Address - Country:US
Mailing Address - Phone:207-286-3689
Mailing Address - Fax:
Practice Address - Street 1:37 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1032
Practice Address - Country:US
Practice Address - Phone:207-780-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-15
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer