Provider Demographics
NPI:1497546600
Name:DIKEMAN, LOGAN SHEA
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:SHEA
Last Name:DIKEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-3210
Mailing Address - Country:US
Mailing Address - Phone:802-779-8269
Mailing Address - Fax:
Practice Address - Street 1:7 COURT SQ
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4030
Practice Address - Country:US
Practice Address - Phone:802-775-4388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator