Provider Demographics
NPI:1619732302
Name:SANGIACOMO, MEGHAN (RBT)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:SANGIACOMO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3779 WARD LOOP UNIT A
Mailing Address - Street 2:
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-4664
Mailing Address - Country:US
Mailing Address - Phone:575-491-8464
Mailing Address - Fax:
Practice Address - Street 1:17301 BEAUJOLAIS CIR
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7513
Practice Address - Country:US
Practice Address - Phone:907-232-5282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK24-326695106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician