Basic Information
| Provider Information | |||||||||
| NPI: | 1730843954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOONEYHAN | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | ELISABETH | ||||||||
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| OtherLastName: | FOUST | ||||||||
| OtherFirstName: | ERIN | ||||||||
| OtherMiddleName: | ELISABETH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2712 W 1000 N | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463609622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742744482 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1120 S CALUMET RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463043286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199839675 | ||||||||
| FaxNumber: | 2199839681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2021 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.