Healthcare Provider Details

I. General information

NPI: 1144311184
Provider Name (Legal Business Name): EAGAN COUNSELING CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 OLEARY LN
EAGAN MN
55123-2340
US

IV. Provider business mailing address

3450 OLEARY LN
EAGAN MN
55123-2340
US

V. Phone/Fax

Practice location:
  • Phone: 651-454-0114
  • Fax: 651-454-3492
Mailing address:
  • Phone: 651-454-0114
  • Fax: 651-454-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number800689-2-MHC
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number800689-2-MHC
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number800689-2-MHC
License Number StateMN

VIII. Authorized Official

Name: PEGGY DOMINIC
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 651-365-8217