=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629745393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEGAN FREED, LMSW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2021
-----------------------------------------------------
Last Update Date | 08/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 640 ROMENCE RD STE 211
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-638-4155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6749 S WESTNEDGE AVE STE K
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002-3556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-638-4155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MEGAN FREED
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 616-638-4155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------