Provider Demographics
NPI:1962912659
Name:LOGAN, JUSTIN WALTER (AT, ATC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WALTER
Last Name:LOGAN
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 NAVARRE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-1348
Mailing Address - Country:US
Mailing Address - Phone:734-552-8862
Mailing Address - Fax:
Practice Address - Street 1:1247 E SIENA HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1755
Practice Address - Country:US
Practice Address - Phone:517-264-7870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-07
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010017862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer