Provider Demographics
NPI:1841462751
Name:MEHLAN, DOUGLAS HERBERT (PT)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:HERBERT
Last Name:MEHLAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:14660 HERRIMAN BLVD STE 300
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4869
Practice Address - Country:US
Practice Address - Phone:317-774-7744
Practice Address - Fax:317-774-7755
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070002119225100000X
IN05011593A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201260400Medicaid
IN555850047Medicare PIN