Provider Demographics
NPI:1962688150
Name:SISSON, MEGAN M (PT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:SISSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:200 OKATIE VILLAGE DR
Practice Address - Street 2:STES 105-106
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-7528
Practice Address - Country:US
Practice Address - Phone:843-706-2861
Practice Address - Fax:843-706-2864
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4603-024225100000X
SC8032225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7738OtherDEAN HEALTH INSURANCE