Healthcare Provider Details

I. General information

NPI: 1790332773
Provider Name (Legal Business Name): MEGAN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 5TH AVE SE
DEVILS LAKE ND
58301-3649
US

IV. Provider business mailing address

500 14TH AVE NE APT 33
DEVILS LAKE ND
58301-2819
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-7690
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14175190
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: