MEDICARE: MEGAN VAN NAME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA 12590	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750630091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN VAN NAME

Provider Business Mailing Address
First Line	:	1242 N DUVAL ST
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32303-6115
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1242 N DUVAL ST
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32303-6115
Country	:	US
Telephone Number	:	941-920-0734
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2012
Last Update Date	:	02/28/2019

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Directions to “ MEGAN VAN NAME ” Practice Location

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