MEDICARE: MEGAN N. DIVINE PT

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	225100000X	Physical Therapist	12142-24	WI
2	208100000X	Physical Medicine & Rehabilitation Physician	PTL.0013053	CO

General Provider Information

NPI Number	:	1942640925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN N. DIVINE PT

Provider Business Mailing Address
First Line	:	25117 SW PARKWAY AVE STE D
Second Line	:
City	:	WILSONVILLE
State	:	OR
Zip	:	97070-9697
Country	:	US
Telephone Number	:	503-744-5406
Fax Number	:

Provider Business Practice Location Address
First Line	:	7600 SANDY ROCK PT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924-5222
Country	:	US
Telephone Number	:	503-744-5406
Fax Number	:

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

Provider Enumeration Date	:	07/05/2013
Last Update Date	:	07/12/2021

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