Provider Demographics
NPI:1356853956
Name:MORAVIAN, MEGAN COMMEDO
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:COMMEDO
Last Name:MORAVIAN
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 1:3428 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3254
Mailing Address - Country:US
Mailing Address - Phone:336-542-0581
Mailing Address - Fax:
Practice Address - Street 1:7604 FAIRHAVEN RD
Practice Address - Street 2:
Practice Address - City:BROWNS SUMMIT
Practice Address - State:NC
Practice Address - Zip Code:27214-9643
Practice Address - Country:US
Practice Address - Phone:336-554-3486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-04
Last Update Date:2017-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-1142320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities