Provider Demographics
NPI:1578061867
Name:GUSHIKEN, LOGAN M (DPT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:M
Last Name:GUSHIKEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PENNSYLVANIA AVE STE 213
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50316-2365
Mailing Address - Country:US
Mailing Address - Phone:515-224-1414
Mailing Address - Fax:515-224-5140
Practice Address - Street 1:1301 PENNSYLVANIA AVE STE 213
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2365
Practice Address - Country:US
Practice Address - Phone:515-224-1414
Practice Address - Fax:515-224-5410
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA090351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist