Basic Information
| Provider Information | |||||||||
| NPI: | 1144759184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLOWSKY | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MSED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4646 W JEFFERSON BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468046832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604360932 | ||||||||
| FaxNumber: | 2604361185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2017 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 35002104A | IN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.