Healthcare Provider Details

I. General information

NPI: 1225451685
Provider Name (Legal Business Name): DAVID JON EAGLE PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6719 CORAL LEAF LN
RIVERSIDE CA
92506-6213
US

IV. Provider business mailing address

6719 CORAL LEAF LN
RIVERSIDE CA
92506-6213
US

V. Phone/Fax

Practice location:
  • Phone: 951-789-9144
  • Fax: 951-789-9144
Mailing address:
  • Phone: 951-789-9144
  • Fax: 951-789-9144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY14978
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY14978
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: