Provider Demographics
NPI:1740812569
Name:EGGLESON, COLIN
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:EGGLESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E CHURCH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-2299
Mailing Address - Country:US
Mailing Address - Phone:815-786-8606
Mailing Address - Fax:815-786-1541
Practice Address - Street 1:207 E CHURCH ST UNIT A
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-2299
Practice Address - Country:US
Practice Address - Phone:815-786-8606
Practice Address - Fax:815-786-1541
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000787101YM0800X
IL166001509106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health