Provider Demographics
NPI:1518631308
Name:EGAN, MALISSA
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:
Last Name:EGAN
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 1:4520 OAK FAIR BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-7356
Mailing Address - Country:US
Mailing Address - Phone:813-542-5500
Mailing Address - Fax:
Practice Address - Street 1:4520 OAK FAIR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-7356
Practice Address - Country:US
Practice Address - Phone:813-542-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical