Provider Demographics
NPI:1356026439
Name:KOVACICH, MEGAN RYAN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:RYAN
Last Name:KOVACICH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:RYAN
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:20699 NE GLISAN ST APT 229
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-3848
Mailing Address - Country:US
Mailing Address - Phone:509-554-4294
Mailing Address - Fax:
Practice Address - Street 1:2505 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3146
Practice Address - Country:US
Practice Address - Phone:503-661-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61441777235Z00000X
OR16790235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist