Provider Demographics
NPI:1124501978
Name:MEGAN, AUTUMN T (MSOT)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:T
Last Name:MEGAN
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 DUE WEST RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-2125
Mailing Address - Country:US
Mailing Address - Phone:770-443-9672
Mailing Address - Fax:
Practice Address - Street 1:3044 DUE WEST ROAD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-3015
Practice Address - Country:US
Practice Address - Phone:177-044-3967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007133225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist