Provider Demographics
NPI:1104390954
Name:GREEN, MEGHAN
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:GREEN
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 1:1925 GROVE AVE APT 312
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1756
Mailing Address - Country:US
Mailing Address - Phone:630-546-2719
Mailing Address - Fax:
Practice Address - Street 1:3443 S 55TH AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-3959
Practice Address - Country:US
Practice Address - Phone:708-780-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242005191235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist