Healthcare Provider Details

I. General information

NPI: 1447985288
Provider Name (Legal Business Name): MEGAN A HEADD RADT 1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

6350 PAGE LN
EL DORADO CA
95623-4304
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9240
  • Fax:
Mailing address:
  • Phone: 916-539-9551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1476820822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: