Provider Demographics
NPI:1184459588
Name:MAXSON, MEGAN ALICIA
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ALICIA
Last Name:MAXSON
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 1:1565 SOUTHHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-4501
Mailing Address - Country:US
Mailing Address - Phone:573-747-9210
Mailing Address - Fax:
Practice Address - Street 1:1015 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2394
Practice Address - Country:US
Practice Address - Phone:636-496-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024035265225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant