Provider Demographics
NPI:1003395401
Name:DAVIS, MEGAN HEATHER (PTA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:HEATHER
Last Name:DAVIS
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 1:855 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-7736
Mailing Address - Country:US
Mailing Address - Phone:912-344-1115
Mailing Address - Fax:
Practice Address - Street 1:855 THOMAS ST
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-7736
Practice Address - Country:US
Practice Address - Phone:912-344-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2079119225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant