Provider Demographics
NPI:1942640925
Name:DIVINE, MEGAN N (PT)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:N
Last Name:DIVINE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25117 SW PARKWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:503-744-5406
Mailing Address - Fax:
Practice Address - Street 1:7600 SANDY ROCK PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80924-5222
Practice Address - Country:US
Practice Address - Phone:503-744-5406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12142-24225100000X
COPTL.0013053208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist