Provider Demographics
NPI:1306192810
Name:WALLACE, MEGAN M (AUD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:WALLACE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:M
Other - Last Name:HEMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:815-971-9729
Practice Address - Street 1:2502 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3738
Practice Address - Country:US
Practice Address - Phone:309-663-4368
Practice Address - Fax:095-245-3573
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001429231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist