Provider Demographics
NPI:1437142288
Name:EGGLESTON, MARY J (MS ED)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:EGGLESTON
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 S BROWN PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6582
Mailing Address - Country:US
Mailing Address - Phone:605-332-1700
Mailing Address - Fax:605-336-9031
Practice Address - Street 1:2210 S BROWN PL
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6582
Practice Address - Country:US
Practice Address - Phone:605-332-1700
Practice Address - Fax:605-336-9031
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC 537101YP2500X
SDLMFT1015106H00000X
SD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist