Provider Demographics
NPI:1487478988
Name:LOE, MEGAN M (BIS)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:LOE
Suffix:
Gender:F
Credentials:BIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3038
Mailing Address - Country:US
Mailing Address - Phone:208-568-0957
Mailing Address - Fax:
Practice Address - Street 1:1322 10TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3038
Practice Address - Country:US
Practice Address - Phone:208-568-0957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist