Provider Demographics
NPI:1184359036
Name:GROVESTEEN, LOGAN THERESE
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:THERESE
Last Name:GROVESTEEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 DONNA AVE
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-2228
Mailing Address - Country:US
Mailing Address - Phone:608-387-1585
Mailing Address - Fax:
Practice Address - Street 1:1175 BLUE IRIS CT
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4241
Practice Address - Country:US
Practice Address - Phone:715-712-1299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant