Healthcare Provider Details

I. General information

NPI: 1144759184
Provider Name (Legal Business Name): LOGAN J. ELLOWSKY MSED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 W JEFFERSON BLVD STE 100
FORT WAYNE IN
46804-6832
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-0932
  • Fax: 260-436-1185
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35002104A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: