Provider Demographics
NPI:1992901763
Name:MEVIS, BONNIE (MPT)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:
Last Name:MEVIS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-1419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1203 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3221
Practice Address - Country:US
Practice Address - Phone:219-326-2397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008814A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist