Healthcare Provider Details

I. General information

NPI: 1396280822
Provider Name (Legal Business Name): ANDREW EGAN LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AYLSWORTH AVE
WOONSOCKET RI
02895-4714
US

IV. Provider business mailing address

400 AYLSWORTH AVE
WOONSOCKET RI
02895-4714
US

V. Phone/Fax

Practice location:
  • Phone: 312-316-6121
  • Fax: 312-316-6121
Mailing address:
  • Phone: 401-312-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW01863
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberCSW01863
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: