Basic Information
| Provider Information | |||||||||
| NPI: | 1467630822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESSMAN | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROEDER | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8881 ROUTE 97 | ||||||||
| Address2: | |||||||||
| City: | CALLICOON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4583336882 | ||||||||
| FaxNumber: | 8458874656 | ||||||||
| Practice Location | |||||||||
| Address1: | 8881 ROUTE 97 | ||||||||
| Address2: | |||||||||
| City: | CALLICOON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453336882 | ||||||||
| FaxNumber: | 8458874656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2008 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 029966 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251P0200X | 029966 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 029966 | 01 | NY | STATE LICENSE | OTHER |