Provider Demographics
NPI:1548218167
Name:HOUGLUM, DANIEL E (MSPT ATC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:HOUGLUM
Suffix:
Gender:M
Credentials:MSPT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2998 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5329
Mailing Address - Country:US
Mailing Address - Phone:262-657-0222
Mailing Address - Fax:262-657-7190
Practice Address - Street 1:15 COMMERCE DR
Practice Address - Street 2:SUITE 106
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-7807
Practice Address - Country:US
Practice Address - Phone:847-548-7782
Practice Address - Fax:847-548-7784
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10070024225100000X
IL070011555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40394300Medicaid
ILIL6238013OtherMEDICARE
ILIL6697006OtherMEDICARE
ILIL6237013OtherMEDICARE
WI859400057OtherMEDICARE
ILL98911Medicare ID - Type Unspecified
WI40394300Medicaid