Provider Demographics
NPI:1972165264
Name:WALLACE-ROSSIO, MEGAN ARLEEN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ARLEEN
Last Name:WALLACE-ROSSIO
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 1:3681 LEAPHART RD STE A
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3068
Mailing Address - Country:US
Mailing Address - Phone:803-590-8548
Mailing Address - Fax:
Practice Address - Street 1:3681 LEAPHART RD STE A
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3068
Practice Address - Country:US
Practice Address - Phone:803-590-8548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA094809231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist