Provider Demographics
NPI:1629544937
Name:STREET, MEGHAN (ALC)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:
Other - Last Name:WORTHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1162
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-5162
Mailing Address - Country:US
Mailing Address - Phone:256-239-5662
Mailing Address - Fax:
Practice Address - Street 1:605A MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-5937
Practice Address - Country:US
Practice Address - Phone:256-239-5662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2716A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional