Provider Demographics
NPI:1497936181
Name:EAGEN, MARY V
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:V
Last Name:EAGEN
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 1:110 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15853-1939
Mailing Address - Country:US
Mailing Address - Phone:814-776-2145
Mailing Address - Fax:
Practice Address - Street 1:110 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853-1939
Practice Address - Country:US
Practice Address - Phone:814-776-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004003101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor