Provider Demographics
NPI:1962236877
Name:SMITH, MEGAN KAY
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:KAY
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:KAY
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10070 N LIMA CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-3224
Mailing Address - Country:US
Mailing Address - Phone:920-220-1427
Mailing Address - Fax:
Practice Address - Street 1:10070 N LIMA CENTER RD
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-3224
Practice Address - Country:US
Practice Address - Phone:920-220-1427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities