Provider Demographics
NPI:1538824594
Name:AVERETT, LOGAN (PT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:AVERETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5690 WATERMELON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5009
Mailing Address - Country:US
Mailing Address - Phone:205-409-6665
Mailing Address - Fax:205-310-3478
Practice Address - Street 1:5690 WATERMELON RD STE 300
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5009
Practice Address - Country:US
Practice Address - Phone:205-409-6665
Practice Address - Fax:205-310-3478
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH10600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist