Basic Information
Provider Information | |||||||||
NPI: | 1699256990 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUCKLEY | ||||||||
FirstName: | LOGAN | ||||||||
MiddleName: | HAVEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3455 HIGHWAY 81 SOUTH | ||||||||
Address2: |   | ||||||||
City: | LOGANVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300523918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7705540665 | ||||||||
FaxNumber: | 7705540685 | ||||||||
Practice Location | |||||||||
Address1: | 1401 CONOWINGO RD STE C | ||||||||
Address2: |   | ||||||||
City: | BEL AIR | ||||||||
State: | MD | ||||||||
PostalCode: | 210141809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104202257 | ||||||||
FaxNumber: | 4104202267 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2018 | ||||||||
LastUpdateDate: | 08/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 27164 | MD | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.