Provider Demographics
NPI:1336566124
Name:EGAN, LOUISE
Entity Type:Individual
Prefix:
First Name:LOUISE
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 1:4220 N 20TH AVE
Mailing Address - Street 2:100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5101
Mailing Address - Country:US
Mailing Address - Phone:602-254-9701
Mailing Address - Fax:602-252-0830
Practice Address - Street 1:4220 N 20TH AVE
Practice Address - Street 2:100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5101
Practice Address - Country:US
Practice Address - Phone:602-254-9701
Practice Address - Fax:602-252-0830
Is Sole Proprietor?:No
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC - 10073101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)