=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366186272
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN RENEE SHAW PRSS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2022
-----------------------------------------------------
Last Update Date | 11/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27750 STATE ROUTE 7
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-5147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-374-5476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27750 STATE ROUTE 7
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-5147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-374-5476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CDCA.181958
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------