Provider Demographics
NPI:1508971599
Name:EGAN, TERESA ANNE (PHD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANNE
Last Name:EGAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35104 EUCLID AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4516
Mailing Address - Country:US
Mailing Address - Phone:440-951-9669
Mailing Address - Fax:440-951-8117
Practice Address - Street 1:6505 ROCKSIDE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2342
Practice Address - Country:US
Practice Address - Phone:216-524-1900
Practice Address - Fax:216-524-9823
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4158103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP12442Medicare PIN