Provider Demographics
NPI:1144311184
Name:EAGAN COUNSELING CLINIC
Entity type:Organization
Organization Name:EAGAN COUNSELING CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-365-8217
Mailing Address - Street 1:3450 OLEARY LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2340
Mailing Address - Country:US
Mailing Address - Phone:651-454-0114
Mailing Address - Fax:651-454-3492
Practice Address - Street 1:3450 OLEARY LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2340
Practice Address - Country:US
Practice Address - Phone:651-454-0114
Practice Address - Fax:651-454-3492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN800689-2-MHC251B00000X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800084OtherPREFERRED ONE
MN59280EAOtherBCBS
MN00892OtherHEALTH PARTNERS
MN101973OtherUCARE
MN84-57408OtherMEDICA
MN800084OtherPREFERRED ONE