Provider Demographics
NPI:1942602073
Name:SMALLWOOD, MEAGAN (COTA)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-3769
Mailing Address - Country:US
Mailing Address - Phone:502-718-8227
Mailing Address - Fax:
Practice Address - Street 1:1550 RAYDALE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-5031
Practice Address - Country:US
Practice Address - Phone:502-968-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-A5952224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant