Provider Demographics
NPI:1457566689
Name:EGGUM, AUDRA A (LCSW)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:A
Last Name:EGGUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:140 W MAIN
Mailing Address - City:WINNECONNE
Mailing Address - State:WI
Mailing Address - Zip Code:54986-0486
Mailing Address - Country:US
Mailing Address - Phone:920-582-4000
Mailing Address - Fax:
Practice Address - Street 1:140 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:WINNECONNE
Practice Address - State:WI
Practice Address - Zip Code:54986-9409
Practice Address - Country:US
Practice Address - Phone:920-582-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1556-1211041C0700X
WI7281-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40923500Medicaid