Provider Demographics
NPI:1790353035
Name:MACNEIL, MEGAN MICHELLE
Entity Type:Individual
Prefix:MISS
First Name:MEGAN
Middle Name:MICHELLE
Last Name:MACNEIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3653 HIDDEN HAVEN ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-7509
Mailing Address - Country:US
Mailing Address - Phone:501-513-7638
Mailing Address - Fax:
Practice Address - Street 1:938 POULSON ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2142
Practice Address - Country:US
Practice Address - Phone:501-513-7638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID106S00000XMedicaid