Provider Demographics
NPI:1174084859
Name:PACK, MEGAN MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:MICHELLE
Last Name:PACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:MICHELLE
Other - Last Name:VALENTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1270 E POWELL RD
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-8619
Mailing Address - Country:US
Mailing Address - Phone:614-981-2065
Mailing Address - Fax:
Practice Address - Street 1:1270 E POWELL RD
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-8619
Practice Address - Country:US
Practice Address - Phone:614-981-2065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14375400692251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports