Healthcare Provider Details

I. General information

NPI: 1952877201
Provider Name (Legal Business Name): KRISTEN ELIZABETH LOGAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2018
Last Update Date: 10/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 E MICHIGAN AVE
MARSHALL MI
49068-2045
US

IV. Provider business mailing address

205 KINGMAN AVE E
BATTLE CREEK MI
49014-5138
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-4251
  • Fax:
Mailing address:
  • Phone: 517-418-0031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502005684
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: