Provider Demographics
NPI:1861833758
Name:EHLERS, DAVID MARK
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MARK
Last Name:EHLERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 W HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8657
Mailing Address - Country:US
Mailing Address - Phone:309-370-8488
Mailing Address - Fax:
Practice Address - Street 1:108 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3918
Practice Address - Country:US
Practice Address - Phone:309-827-5351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178009754101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health