Provider Demographics
NPI:1659517266
Name:LARSON, MEGAN LEILANI
Entity type:Individual
Prefix:MISS
First Name:MEGAN
Middle Name:LEILANI
Last Name:LARSON
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 1:1403 DECLARATION DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2507
Mailing Address - Country:US
Mailing Address - Phone:813-352-1104
Mailing Address - Fax:
Practice Address - Street 1:1403 DECLARATION DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-2507
Practice Address - Country:US
Practice Address - Phone:813-352-1104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-02
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28634235Z00000X
FLSA10728235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist