Healthcare Provider Details

I. General information

NPI: 1689070757
Provider Name (Legal Business Name): LAURA EAGLE MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 MEDICAL CENTER DR
RAINELLE WV
25962-1064
US

IV. Provider business mailing address

176 MEDICAL CENTER DR
RAINELLE WV
25962-1064
US

V. Phone/Fax

Practice location:
  • Phone: 304-438-6188
  • Fax: 304-438-6819
Mailing address:
  • Phone: 304-438-6188
  • Fax: 304-438-6819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberBPOO943647
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCP00943647
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00943647
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: