Provider Demographics
NPI:1740654136
Name:ANTALIS, MEGAN ELLEN
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:ELLEN
Last Name:ANTALIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 S RYAN PL
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4378
Mailing Address - Country:US
Mailing Address - Phone:419-234-7093
Mailing Address - Fax:
Practice Address - Street 1:2770 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3242
Practice Address - Country:US
Practice Address - Phone:812-323-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005218A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant