Provider Demographics
NPI:1093564809
Name:EAGEN, TRICIA (LPC)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:EAGEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SHURA
Other - Middle Name:
Other - Last Name:EAGEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1829 W STADIUM BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-7009
Mailing Address - Country:US
Mailing Address - Phone:458-215-1356
Mailing Address - Fax:
Practice Address - Street 1:104 W 4TH ST STE 204
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3803
Practice Address - Country:US
Practice Address - Phone:458-215-1356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401223026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health