Provider Demographics
NPI:1619007531
Name:SYPOLT, MEGAN MILLER (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MILLER
Last Name:SYPOLT
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 1:4820 INNISBROOK CT S
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:FL
Mailing Address - Zip Code:32033-2067
Mailing Address - Country:US
Mailing Address - Phone:904-217-5437
Mailing Address - Fax:
Practice Address - Street 1:4820 INNISBROOK CT S
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:FL
Practice Address - Zip Code:32033-2067
Practice Address - Country:US
Practice Address - Phone:904-217-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8548235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891103700Medicaid