Healthcare Provider Details

I. General information

NPI: 1235048943
Provider Name (Legal Business Name): MR. KEVIN MICHAEL EAGLESON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 JOSEPH CT
SAN RAFAEL CA
94903-2664
US

IV. Provider business mailing address

211 MISSION DR
PETALUMA CA
94952-5281
US

V. Phone/Fax

Practice location:
  • Phone: 415-785-4993
  • Fax: 415-599-4362
Mailing address:
  • Phone: 415-408-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: