Provider Demographics
NPI:1407154511
Name:EGAN, REBECCA A (MSE)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:A
Last Name:EGAN
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 LAKELAND RD
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3836
Mailing Address - Country:US
Mailing Address - Phone:715-256-5547
Mailing Address - Fax:715-526-5542
Practice Address - Street 1:504 LAKELAND RD
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3836
Practice Address - Country:US
Practice Address - Phone:715-526-5547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI715-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor