Provider Demographics
NPI:1902638042
Name:WOOLF, LOGAN GLEN (DPT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:GLEN
Last Name:WOOLF
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13255 S HIGHWAY 265
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72753-8340
Mailing Address - Country:US
Mailing Address - Phone:573-247-2893
Mailing Address - Fax:
Practice Address - Street 1:6700 CHAD COLLEY BLVD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-6120
Practice Address - Country:US
Practice Address - Phone:479-974-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist