Provider Demographics
NPI:1609641125
Name:WALLACE, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:WALLACE
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:GREENFIELD REHAB AGENCY
Mailing Address - Street 2:3360 GATEWAY ROAD
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:GREENFIELD REHAB AGENCY
Practice Address - Street 2:3360 GATEWAY ROAD
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045
Practice Address - Country:US
Practice Address - Phone:262-923-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist