Provider Demographics
NPI:1952877201
Name:LOGAN, KRISTEN ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELIZABETH
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 KINGMAN AVE E
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-5138
Mailing Address - Country:US
Mailing Address - Phone:517-418-0031
Mailing Address - Fax:
Practice Address - Street 1:879 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-2045
Practice Address - Country:US
Practice Address - Phone:269-781-4251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005684225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant