Basic Information
| Provider Information | |||||||||
| NPI: | 1508321597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAAS | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 N ROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611033619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2019 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070023681 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1508321597 | 05 | WI | MEDICAID |