Provider Demographics
NPI:1346660602
Name:MEGAHAN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MEGAHAN
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:PO BOX 50304
Mailing Address - Street 2:
Mailing Address - City:PARKS
Mailing Address - State:AZ
Mailing Address - Zip Code:86018-0304
Mailing Address - Country:US
Mailing Address - Phone:928-853-4152
Mailing Address - Fax:
Practice Address - Street 1:3011 S SYCAMORE CANYON DRIVE
Practice Address - Street 2:
Practice Address - City:PARKS
Practice Address - State:AZ
Practice Address - Zip Code:86018-0304
Practice Address - Country:US
Practice Address - Phone:928-853-4152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3092313320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness