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General NPI Number Information
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NPI Number | 1912120767
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Entity Type | Individual
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Provider Name | LESA MARIE MEHL P.T.
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Gender | Female
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 10/14/2012
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Provider Practice Location Address
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Address Line | 3524 N BROADWAY ST APT 1 NORTH
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City | CHICAGO
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State | IL
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Zip | 60657-1867
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Country | US
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Telephone | 617-877-2354
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Fax |
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Provider Business Mailing Address
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Address Line | 2150 W CONCORD PL #1
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City | CHICAGO
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State | IL
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Zip | 60647-5407
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Country | US
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Telephone | 617-877-2354
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Fax | 773-305-5151
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 16910
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 70014093
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License Number State | IL
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