Healthcare Provider Details

I. General information

NPI: 1477833796
Provider Name (Legal Business Name): MEGHAN FUNK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 W EAU GALLIE BLVD SUITE 180
MELBOURNE FL
32934-7213
US

IV. Provider business mailing address

1010 CAYMAN DR
MELBOURNE FL
32901-8645
US

V. Phone/Fax

Practice location:
  • Phone: 321-255-6627
  • Fax:
Mailing address:
  • Phone: 727-729-2152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI1979
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: