Provider Demographics
NPI:1518253905
Name:WALLACE, MEGAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12679 TWIN PEAK CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-8403
Mailing Address - Country:US
Mailing Address - Phone:951-684-6500
Mailing Address - Fax:
Practice Address - Street 1:6180 BROCKTON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2228
Practice Address - Country:US
Practice Address - Phone:951-684-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19025235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist