Basic Information
Provider Information | |||||||||
NPI: | 1548218167 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOUGLUM | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSPT ATC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2998 MOMENTUM PL | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606895329 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626570222 | ||||||||
FaxNumber: | 2626577190 | ||||||||
Practice Location | |||||||||
Address1: | 15 COMMERCE DR | ||||||||
Address2: | SUITE 106 | ||||||||
City: | GRAYSLAKE | ||||||||
State: | IL | ||||||||
PostalCode: | 600307807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475487782 | ||||||||
FaxNumber: | 8475487784 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 12/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10070024 | WI | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | 070011555 | IL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 40394300 | 05 | WI |   | MEDICAID | IL6238013 | 01 | IL | MEDICARE | OTHER | IL6697006 | 01 | IL | MEDICARE | OTHER | IL6237013 | 01 | IL | MEDICARE | OTHER | 859400057 | 01 | WI | MEDICARE | OTHER |