Provider Demographics
NPI:1982726204
Name:MIMM, MEGAN LEIGH (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:LEIGH
Last Name:MIMM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N PROGRESS AVE APT J11
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-6521
Mailing Address - Country:US
Mailing Address - Phone:724-456-0738
Mailing Address - Fax:
Practice Address - Street 1:1205 S 28TH ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-1046
Practice Address - Country:US
Practice Address - Phone:717-565-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL009086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist