Provider Demographics
NPI:1811945843
Name:EGAN, ELEANOR KATHERINE (MED LMHC)
Entity type:Individual
Prefix:MS
First Name:ELEANOR
Middle Name:KATHERINE
Last Name:EGAN
Suffix:
Gender:F
Credentials:MED LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HANSON AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3714
Mailing Address - Country:US
Mailing Address - Phone:617-435-6714
Mailing Address - Fax:
Practice Address - Street 1:23 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4403
Practice Address - Country:US
Practice Address - Phone:617-435-6714
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3710101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALM0834OtherBC/SPROVIDER
MA3710OtherLMHC LICENSE