Provider Demographics
NPI:1033693445
Name:ISRAELSEN, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:ISRAELSEN
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 1:356 N 300 W APT 6
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3855
Mailing Address - Country:US
Mailing Address - Phone:303-829-2796
Mailing Address - Fax:
Practice Address - Street 1:356 N 300 W APT 6
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3855
Practice Address - Country:US
Practice Address - Phone:303-829-2796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10950506-4104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist