Healthcare Provider Details

I. General information

NPI: 1578089520
Provider Name (Legal Business Name): MEGAN SELF DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10390 COLOMA RD STE 7
RANCHO CORDOVA CA
95670-2152
US

IV. Provider business mailing address

2802 SCANDIA WAY
CARMICHAEL CA
95608-4016
US

V. Phone/Fax

Practice location:
  • Phone: 916-858-0950
  • Fax: 916-759-8681
Mailing address:
  • Phone: 916-844-9332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number293625
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: