Provider Demographics
NPI:1619783677
Name:EGBEGBETORO, JOYCE
Entity type:Individual
Prefix:
First Name:JOYCE
Middle Name:
Last Name:EGBEGBETORO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 110TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4173
Mailing Address - Country:US
Mailing Address - Phone:612-456-6090
Mailing Address - Fax:
Practice Address - Street 1:2119 110TH LN NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4173
Practice Address - Country:US
Practice Address - Phone:612-456-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health