Provider Demographics
NPI:1538258066
Name:LOGAN, PORTLAND E (PT)
Entity type:Individual
Prefix:MRS
First Name:PORTLAND
Middle Name:E
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1850 SULLIVAN AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2221
Mailing Address - Country:US
Mailing Address - Phone:650-756-5630
Mailing Address - Fax:650-756-1964
Practice Address - Street 1:1850 SULLIVAN AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2221
Practice Address - Country:US
Practice Address - Phone:650-756-5630
Practice Address - Fax:650-756-1964
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-09-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA197752251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic