Provider Demographics
NPI:1912120767
Name:MEHL, LESA MARIE (PT)
Entity Type:Individual
Prefix:MISS
First Name:LESA
Middle Name:MARIE
Last Name:MEHL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 W CONCORD PL
Mailing Address - Street 2:#1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5407
Mailing Address - Country:US
Mailing Address - Phone:617-877-2354
Mailing Address - Fax:773-305-5151
Practice Address - Street 1:3524 N BROADWAY ST
Practice Address - Street 2:APT 1 NORTH
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-1867
Practice Address - Country:US
Practice Address - Phone:617-877-2354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2012-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16910225100000X
IL70014093225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist