Healthcare Provider Details

I. General information

NPI: 1740654136
Provider Name (Legal Business Name): MRS. MEGAN ELLEN ANTALIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 S ADAMS ST
BLOOMINGTON IN
47403-3242
US

IV. Provider business mailing address

3129 S RYAN PL
BLOOMINGTON IN
47403-4378
US

V. Phone/Fax

Practice location:
  • Phone: 812-323-4661
  • Fax:
Mailing address:
  • Phone: 419-234-7093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06005218A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: