Provider Demographics
NPI:1902573397
Name:ROLSTON, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:ROLSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-3907
Mailing Address - Country:US
Mailing Address - Phone:920-629-1179
Mailing Address - Fax:
Practice Address - Street 1:1280 PINE HAVEN LN
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085-3001
Practice Address - Country:US
Practice Address - Phone:920-467-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3198-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant