Provider Demographics
NPI:1609589688
Name:OLLIS, MEGAN KENZIE (NC LMBT)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:KENZIE
Last Name:OLLIS
Suffix:
Gender:F
Credentials:NC LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007A BEN BOLEN RD
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:NC
Mailing Address - Zip Code:28615-9518
Mailing Address - Country:US
Mailing Address - Phone:336-620-7125
Mailing Address - Fax:
Practice Address - Street 1:203B LONG ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9518
Practice Address - Country:US
Practice Address - Phone:336-620-7125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15736225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNOT AVAILABLE