Provider Demographics
NPI:1407416258
Name:BLACK, MEGAN NICOLE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:NICOLE
Last Name:BLACK
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 1:140 LAKE CONCORD RD NE APT A6
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-0902
Mailing Address - Country:US
Mailing Address - Phone:704-791-5807
Mailing Address - Fax:
Practice Address - Street 1:644 ABINGTON DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2568
Practice Address - Country:US
Practice Address - Phone:704-239-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13026235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist