Provider Demographics
NPI:1295485050
Name:LOGAN, TYLER (DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 SHINING WILLOW WAY UNIT 307
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-4224
Mailing Address - Country:US
Mailing Address - Phone:301-818-6753
Mailing Address - Fax:
Practice Address - Street 1:12510 FAIRWOOD PKWY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-6343
Practice Address - Country:US
Practice Address - Phone:301-859-0003
Practice Address - Fax:240-913-9223
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist