Provider Demographics
NPI:1487808796
Name:EAGLE, MARY THERESE (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESE
Last Name:EAGLE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3239 CIRCLE CREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116
Mailing Address - Country:US
Mailing Address - Phone:503-359-9789
Mailing Address - Fax:503-359-0929
Practice Address - Street 1:10700 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:SUITE 525
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3019
Practice Address - Country:US
Practice Address - Phone:503-359-9789
Practice Address - Fax:503-359-0929
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1841101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional