Provider Demographics
NPI:1316679681
Name:EGAN, LEAH ALICE (CTRS,NBCWHC,ATA)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:ALICE
Last Name:EGAN
Suffix:
Gender:F
Credentials:CTRS,NBCWHC,ATA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55320-2040
Mailing Address - Country:US
Mailing Address - Phone:715-220-2251
Mailing Address - Fax:
Practice Address - Street 1:700 DIVISION ST
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1336
Practice Address - Country:US
Practice Address - Phone:715-220-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN61501225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Multi-Specialty