Provider Demographics
NPI:1033324298
Name:MOURNING, TODD ALAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:ALAN
Last Name:MOURNING
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 STAHLHUT DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-5066
Mailing Address - Country:US
Mailing Address - Phone:217-605-5501
Mailing Address - Fax:217-732-3101
Practice Address - Street 1:200 STAHLHUT DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-5066
Practice Address - Country:US
Practice Address - Phone:217-605-5501
Practice Address - Fax:217-732-3101
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.009619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist