Provider Demographics
NPI:1720175615
Name:LOGUE, BRETT EVAN (PT)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:EVAN
Last Name:LOGUE
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 1:180 E PULASKI RD
Mailing Address - Street 2:SUITE C, LOWER LEVEL
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1915
Mailing Address - Country:US
Mailing Address - Phone:631-396-1595
Mailing Address - Fax:631-396-1597
Practice Address - Street 1:180 E PULASKI RD
Practice Address - Street 2:SUITE C, LOWER LEVEL
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1915
Practice Address - Country:US
Practice Address - Phone:631-396-1595
Practice Address - Fax:631-396-1597
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017678-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00800649OtherRAILROAD MEDICARE
NY03167668Medicaid
NYQ25Z21Medicare PIN