Healthcare Provider Details

I. General information

NPI: 1518285105
Provider Name (Legal Business Name): MEGAN GUSTAEVEL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2010
Last Update Date: 05/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S ARCH AVE
ALLIANCE OH
44601-4202
US

IV. Provider business mailing address

845 LILLY RD
ALLIANCE OH
44601-3812
US

V. Phone/Fax

Practice location:
  • Phone: 330-821-0201
  • Fax:
Mailing address:
  • Phone: 330-581-1536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT878
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: