Provider Demographics
NPI:1144759184
Name:ELLOWSKY, LOGAN J (MSED)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:J
Last Name:ELLOWSKY
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4646 W JEFFERSON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6832
Practice Address - Country:US
Practice Address - Phone:260-436-0932
Practice Address - Fax:260-436-1185
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35002104A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist