Healthcare Provider Details

I. General information

NPI: 1316595994
Provider Name (Legal Business Name): MEGAN MARIE HURT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N WOLF RD
NORTHLAKE IL
60164-1670
US

IV. Provider business mailing address

612 W PATTERSON AVE APT 401
CHICAGO IL
60613-4458
US

V. Phone/Fax

Practice location:
  • Phone: 708-409-2131
  • Fax:
Mailing address:
  • Phone: 636-584-9849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146014074
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: