Provider Demographics
NPI:1265634448
Name:LAURIE, MEGAN DIANE (PTA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:DIANE
Last Name:LAURIE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:DIANE
Other - Last Name:HAWK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:415 S 10TH ST
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-2771
Practice Address - Country:US
Practice Address - Phone:913-370-9501
Practice Address - Fax:913-937-9423
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01497225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant