Provider Demographics
NPI:1194537233
Name:LOGAN, ELLEN (CTRS, TRS)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:CTRS, TRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MING AVE STE 265
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-4696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:266 LEFT FORK HOBBLE CREEK CANYON RD
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663
Practice Address - Country:US
Practice Address - Phone:385-500-3529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12454141-4002225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12454141-4002OtherLICENSE