Provider Demographics
NPI:1235157512
Name:EGGERTSEN, CLAUDE WAKEFIELD (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLAUDE
Middle Name:WAKEFIELD
Last Name:EGGERTSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52976 WESTCREEK DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-2976
Mailing Address - Country:US
Mailing Address - Phone:586-677-7810
Mailing Address - Fax:586-677-7809
Practice Address - Street 1:288 S MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ROMEO
Practice Address - State:MI
Practice Address - Zip Code:48065-5133
Practice Address - Country:US
Practice Address - Phone:248-496-2871
Practice Address - Fax:586-677-7809
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X, 103TC2200X
MI003213103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP38540001Medicare ID - Type Unspecified
MIR67170Medicare UPIN