Provider Demographics
NPI:1639427545
Name:GIESE, MEGAN CAMILLE (SLP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:CAMILLE
Last Name:GIESE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 GAVIN DR NW
Mailing Address - Street 2:PAINTED SKY ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5536
Mailing Address - Country:US
Mailing Address - Phone:505-836-7763
Mailing Address - Fax:
Practice Address - Street 1:8101 GAVIN DR NW
Practice Address - Street 2:PAINTED SKY ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-5536
Practice Address - Country:US
Practice Address - Phone:505-836-7763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC 5170235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNONE ASSIGNEDMedicaid