Provider Demographics
NPI:1053524074
Name:LOGAN, HOLLY MAURINE (MSPT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:MAURINE
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6890 E. SUNRISE DR SUITE 120-353
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750
Mailing Address - Country:US
Mailing Address - Phone:970-390-1594
Mailing Address - Fax:
Practice Address - Street 1:1601 W. ST. MARY'S ROAD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745
Practice Address - Country:US
Practice Address - Phone:520-872-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7055225100000X
CO5177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist