Provider Demographics
NPI:1790897627
Name:EAGLE, LEEANN (MS, OTR L)
Entity Type:Individual
Prefix:MS
First Name:LEEANN
Middle Name:
Last Name:EAGLE
Suffix:
Gender:F
Credentials:MS, OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2778 COUNTRY CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443
Mailing Address - Country:US
Mailing Address - Phone:910-821-1035
Mailing Address - Fax:
Practice Address - Street 1:2778 COUNTRY CLUB DRIVE
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443
Practice Address - Country:US
Practice Address - Phone:910-821-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4675225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC721634Medicaid
NC721634Medicaid