Healthcare Provider Details

I. General information

NPI: 1508835257
Provider Name (Legal Business Name): MEGAN SUPP ATC, CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N MERION AVE
BRYN MAWR PA
19010-2859
US

IV. Provider business mailing address

202 LAFAYETTE DR
LOGAN TWP NJ
08085-1437
US

V. Phone/Fax

Practice location:
  • Phone: 610-526-7422
  • Fax:
Mailing address:
  • Phone: 267-242-0085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT003435
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: