Provider Demographics
NPI:1295037497
Name:DOLIESLAGER, MEAGAN
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:
Last Name:DOLIESLAGER
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 1:1201 S IH 35
Mailing Address - Street 2:STE 105
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-6615
Mailing Address - Country:US
Mailing Address - Phone:512-310-7665
Mailing Address - Fax:512-310-9228
Practice Address - Street 1:1201 S IH 35 STE 105
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-6646
Practice Address - Country:US
Practice Address - Phone:512-310-7665
Practice Address - Fax:512-310-9228
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109233235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0031DGOtherBLUE CROSS BLUE SHIELD
TX0944746-02Medicaid
74-2745294OtherTAX ID
TX0944746-02Medicaid