Healthcare Provider Details

I. General information

NPI: 1972413458
Provider Name (Legal Business Name): MEGAN BAKKEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51424 VAN DYKE AVE STE 23
SHELBY TOWNSHIP MI
48316-4409
US

IV. Provider business mailing address

516 THORN TREE RD
GROSSE POINTE WOODS MI
48236-2731
US

V. Phone/Fax

Practice location:
  • Phone: 248-895-0031
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: