=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568186047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN HERBRUCK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2022
-----------------------------------------------------
Last Update Date | 09/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3131 SMITH RD
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-666-1183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 644 TREESIDE DR
-----------------------------------------------------
City | STOW
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44224-1151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | COND.20222224-SP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------