Provider Demographics
NPI:1225433733
Name:SMALLEY, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:SMALLEY
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 1:909 DAVIS ST
Mailing Address - Street 2:STE 220
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3683
Mailing Address - Country:US
Mailing Address - Phone:847-733-7906
Mailing Address - Fax:
Practice Address - Street 1:1600 DODGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3449
Practice Address - Country:US
Practice Address - Phone:847-424-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0040982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer