Healthcare Provider Details

I. General information

NPI: 1811400278
Provider Name (Legal Business Name): MEAGAN JEAN WARDEN PTA, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MEAGAN JEAN MAYER

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 W GRAND RIVER AVE
BRIGHTON MI
48116-2392
US

IV. Provider business mailing address

740 W GRAND RIVER
BRIGHTON MI
48116
US

V. Phone/Fax

Practice location:
  • Phone: 810-227-3588
  • Fax:
Mailing address:
  • Phone: 810-227-3588
  • Fax: 810-626-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004372
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501000683
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: