Provider Demographics
NPI:1548630759
Name:LOGAN, EMMA (DPT)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:1108 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4317
Practice Address - Country:US
Practice Address - Phone:360-452-6216
Practice Address - Fax:360-452-8765
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60599449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0346769OtherWA L&I
WAP01614787OtherRR MEDICARE
WA1548630759Medicaid
WA0346769OtherWA L&I