Provider Demographics
NPI:1801450929
Name:PORTER STAATS, MEGAN (PSYD)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:PORTER STAATS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 S ALABAMA ST UNIT 182
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3765
Mailing Address - Country:US
Mailing Address - Phone:330-697-7676
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST # OR6000
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-7874
Practice Address - Fax:706-721-1793
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAPSY004548103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program