Healthcare Provider Details

I. General information

NPI: 1124776000
Provider Name (Legal Business Name): MEGAN FREEMAN LCDC III, QMHS3
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4998 W BROAD ST STE 104
COLUMBUS OH
43228-1647
US

IV. Provider business mailing address

434 EASTLAND RD
BEREA OH
44017-1217
US

V. Phone/Fax

Practice location:
  • Phone: 614-962-6179
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number162456
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: