MEDICARE: MRS. MEGAN GARDNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	242004459	IL

General Provider Information

NPI Number	:	1346752201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MEGAN GARDNER

Provider Business Mailing Address
First Line	:	914 CARLISLE DR APT B
Second Line	:
City	:	ROCHELLE
State	:	IL
Zip	:	61068-1726
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1450 20TH ST
Second Line	:
City	:	ROCHELLE
State	:	IL
Zip	:	61068-1076
Country	:	US
Telephone Number	:	815-562-4520
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2017
Last Update Date	:	11/01/2017

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Directions to “ MRS. MEGAN GARDNER ” Practice Location

Language	Start Address	Practice Location

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