Provider Demographics
NPI:1780464446
Name:YOUNGBLOOD, LOGAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-1240
Mailing Address - Country:US
Mailing Address - Phone:229-296-1489
Mailing Address - Fax:
Practice Address - Street 1:405 LAUREL ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:GA
Practice Address - Zip Code:31639-3030
Practice Address - Country:US
Practice Address - Phone:229-543-7335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist