Provider Demographics
NPI:1396000824
Name:EGAN, TINA MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:EGAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 OVERHILL RD
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:RI
Mailing Address - Zip Code:02857-1158
Mailing Address - Country:US
Mailing Address - Phone:401-473-9429
Mailing Address - Fax:
Practice Address - Street 1:10 OVERHILL RD
Practice Address - Street 2:
Practice Address - City:SCITUATE
Practice Address - State:RI
Practice Address - Zip Code:02857-1158
Practice Address - Country:US
Practice Address - Phone:401-473-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW011981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIISW01198OtherPROFESSIONAL LICENSE