Provider Demographics
NPI:1366980443
Name:BLACKARD, MEGAN (MA 60183881)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BLACKARD
Suffix:
Gender:F
Credentials:MA 60183881
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3722 ROCKEFELLER AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4931
Mailing Address - Country:US
Mailing Address - Phone:425-299-9833
Mailing Address - Fax:
Practice Address - Street 1:3722 ROCKEFELLER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4931
Practice Address - Country:US
Practice Address - Phone:425-299-9833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60183881225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist