Healthcare Provider Details

I. General information

NPI: 1336629500
Provider Name (Legal Business Name): MEGAN SU ROSSELOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 GARWOOD DR
PAINESVILLE OH
44077-5429
US

IV. Provider business mailing address

1155 GARWOOD DR
PAINESVILLE OH
44077-5429
US

V. Phone/Fax

Practice location:
  • Phone: 937-823-9208
  • Fax:
Mailing address:
  • Phone: 937-823-9208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: