Provider Demographics
NPI:1700442506
Name:GABRIELSEN, LOGAN A (OTR/L)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:A
Last Name:GABRIELSEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S 9TH ST
Mailing Address - Street 2:STE 4
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-2631
Mailing Address - Country:US
Mailing Address - Phone:765-524-3946
Mailing Address - Fax:317-708-6496
Practice Address - Street 1:522 6TH BAXTER XING STE B
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6613
Practice Address - Country:US
Practice Address - Phone:803-929-7408
Practice Address - Fax:888-711-0441
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4399224Z00000X
SC5913225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant