Basic Information
| Provider Information | |||||||||
| NPI: | 1700442506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GABRIELSEN | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 S 9TH ST | ||||||||
| Address2: | STE 4 | ||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460602631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655243946 | ||||||||
| FaxNumber: | 3177086496 | ||||||||
| Practice Location | |||||||||
| Address1: | 522 6TH BAXTER XING STE B | ||||||||
| Address2: | |||||||||
| City: | FORT MILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297086613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039297408 | ||||||||
| FaxNumber: | 8887110441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 4399 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225X00000X | 5913 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.