Provider Demographics
NPI:1902205172
Name:EAGLE, KELLIE (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:EAGLE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 SPICER HILL RD
Mailing Address - Street 2:
Mailing Address - City:LEDYARD
Mailing Address - State:CT
Mailing Address - Zip Code:06339-1535
Mailing Address - Country:US
Mailing Address - Phone:860-917-0790
Mailing Address - Fax:860-371-2624
Practice Address - Street 1:28 HAUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOZRAH
Practice Address - State:CT
Practice Address - Zip Code:06334-1207
Practice Address - Country:US
Practice Address - Phone:860-917-0790
Practice Address - Fax:608-371-2624
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator