MEDICARE: MISS LESA MARIE MEHL P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	16910	MA
2	225100000X	Physical Therapist	70014093	IL

General Provider Information

NPI Number	:	1912120767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LESA MARIE MEHL P.T.

Provider Business Mailing Address
First Line	:	2150 W CONCORD PL
Second Line	:	#1
City	:	CHICAGO
State	:	IL
Zip	:	60647-5407
Country	:	US
Telephone Number	:	617-877-2354
Fax Number	:	773-305-5151

Provider Business Practice Location Address
First Line	:	3524 N BROADWAY ST
Second Line	:	APT 1 NORTH
City	:	CHICAGO
State	:	IL
Zip	:	60657-1867
Country	:	US
Telephone Number	:	617-877-2354
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	10/14/2012

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