Healthcare Provider Details

I. General information

NPI: 1558190975
Provider Name (Legal Business Name): MEGAN CISCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 COURT ST
PORTSMOUTH OH
45662-3932
US

IV. Provider business mailing address

411 COURT ST
PORTSMOUTH OH
45662-3932
US

V. Phone/Fax

Practice location:
  • Phone: 740-354-6685
  • Fax: 740-876-4005
Mailing address:
  • Phone: 740-354-6685
  • Fax: 740-876-4005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2024
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number2024
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: