Provider Demographics
NPI:1659939122
Name:GRACE, MEGAN TERESA (ATC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:TERESA
Last Name:GRACE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 GERVAIS ST # 406C
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1803
Mailing Address - Country:US
Mailing Address - Phone:210-487-0840
Mailing Address - Fax:
Practice Address - Street 1:1116 PASADERO DR
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-3011
Practice Address - Country:US
Practice Address - Phone:210-487-0840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC5199492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer