Provider Demographics
NPI:1073668646
Name:EGAN-RUSSO, EILEEN M (LAC, LMT)
Entity Type:Individual
Prefix:MS
First Name:EILEEN
Middle Name:M
Last Name:EGAN-RUSSO
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:MS
Other - First Name:EILEEN
Other - Middle Name:M
Other - Last Name:EGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 STARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-2523
Mailing Address - Country:US
Mailing Address - Phone:917-846-9010
Mailing Address - Fax:
Practice Address - Street 1:348 U.S. 9
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726
Practice Address - Country:US
Practice Address - Phone:732-894-9200
Practice Address - Fax:732-894-9202
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006611-01171100000X
NY013178174400000X
NJ25MZ00142400171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist