Provider Demographics
NPI:1063775856
Name:MOSBACH, JANELL DIANE
Entity type:Individual
Prefix:MRS
First Name:JANELL
Middle Name:DIANE
Last Name:MOSBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4480
Mailing Address - Country:US
Mailing Address - Phone:217-304-6487
Mailing Address - Fax:309-661-2892
Practice Address - Street 1:2401 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4480
Practice Address - Country:US
Practice Address - Phone:217-304-6487
Practice Address - Fax:309-661-2892
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227-010226225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist