Provider Demographics
NPI:1104478874
Name:EAGLEHEAD, RITA (BED)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:EAGLEHEAD
Suffix:
Gender:F
Credentials:BED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 81754
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-1754
Mailing Address - Country:US
Mailing Address - Phone:907-455-4725
Mailing Address - Fax:907-455-4730
Practice Address - Street 1:2550 LAWLOR RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-6458
Practice Address - Country:US
Practice Address - Phone:907-455-4725
Practice Address - Fax:907-455-4730
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool