Provider Demographics
NPI:1841725140
Name:DEVINE, MEGAN ELYSE (MS, L-ATC)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELYSE
Last Name:DEVINE
Suffix:
Gender:F
Credentials:MS, L-ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ROUND VALLEY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7552
Mailing Address - Country:US
Mailing Address - Phone:435-655-6619
Mailing Address - Fax:435-655-2388
Practice Address - Street 1:900 ROUND VALLEY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7552
Practice Address - Country:US
Practice Address - Phone:435-655-6619
Practice Address - Fax:435-655-2388
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9426289-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer