Healthcare Provider Details

I. General information

NPI: 1346095684
Provider Name (Legal Business Name): LOGAN GORAL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2024
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 CLAIREMONT DR
APPLETON WI
54913
US

IV. Provider business mailing address

W6157 ROCK ISLAND DR
GREENVILLE WI
54942-8792
US

V. Phone/Fax

Practice location:
  • Phone: 920-215-1262
  • Fax:
Mailing address:
  • Phone: 262-312-8359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16327-24
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: