Provider Demographics
NPI:1043931702
Name:MARSHALL, LOGAN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:M
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 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:862 MEINECKE AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-3702
Practice Address - Country:US
Practice Address - Phone:805-619-0414
Practice Address - Fax:805-549-5253
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA302630OtherPT LICENSE