Provider Demographics
NPI:1194064998
Name:DAVAULT, MEGAN (PTA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:DAVAULT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22501 HIGHWAY 68
Mailing Address - Street 2:
Mailing Address - City:VICHY
Mailing Address - State:MO
Mailing Address - Zip Code:65580-8243
Mailing Address - Country:US
Mailing Address - Phone:573-578-7041
Mailing Address - Fax:
Practice Address - Street 1:400 TRI COUNTY LANE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MO
Practice Address - Zip Code:65556-1033
Practice Address - Country:US
Practice Address - Phone:573-765-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012014133225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant