Provider Demographics
NPI:1194002444
Name:IVY, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:IVY
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 1:2512 BERKETT DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-4353
Mailing Address - Country:US
Mailing Address - Phone:512-663-4486
Mailing Address - Fax:
Practice Address - Street 1:1600 W 38TH ST
Practice Address - Street 2:201
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6400
Practice Address - Country:US
Practice Address - Phone:512-206-0433
Practice Address - Fax:512-206-0797
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12061312251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic