Provider Demographics
NPI:1396409512
Name:ELISAR, MEGAN (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:ELISAR
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 ARKWRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1302
Mailing Address - Country:US
Mailing Address - Phone:478-477-0601
Mailing Address - Fax:478-477-0133
Practice Address - Street 1:4550 ARKWRIGHT RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1302
Practice Address - Country:US
Practice Address - Phone:478-477-0601
Practice Address - Fax:478-477-0133
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP11806235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist