Provider Demographics
NPI:1881039964
Name:STAKE, MEGAN ELIZABETH (MA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELIZABETH
Last Name:STAKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 BARTLETT ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-2611
Mailing Address - Country:US
Mailing Address - Phone:774-275-1079
Mailing Address - Fax:
Practice Address - Street 1:10J GILL ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1721
Practice Address - Country:US
Practice Address - Phone:781-932-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS81557183222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist