Healthcare Provider Details

I. General information

NPI: 1235448051
Provider Name (Legal Business Name): ROXANNE EAGAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 MT HOPE RD
MIDDLETOWN NY
10940-7135
US

IV. Provider business mailing address

379 MT HOPE RD
MIDDLETOWN NY
10940-7135
US

V. Phone/Fax

Practice location:
  • Phone: 845-344-2292
  • Fax: 845-342-2054
Mailing address:
  • Phone: 845-344-2292
  • Fax: 845-342-2054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number054159-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: