Organization
EAGAN COUNSELING CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PEGGY DOMINIC (CHIEF FINANCIAL OFFICER)
(651) 365-8217
Entity
Organization
Contact information
Practice address
3450 OLEARY LN, EAGAN, MN 55123-2340
(651) 454-0114
(651) 454-3492
Mailing address
3450 OLEARY LN, EAGAN, MN 55123-2340
(651) 454-0114
(651) 454-3492
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
800689-2-MHC
MN
103TP2701X
Group Psychotherapy Psychologist
800689-2-MHC
MN
251B00000X
Case Management Agency
800689-2-MHC
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00892
HEALTH PARTNERS
MN
01
—
101973
UCARE
MN
01
—
59280EA
BCBS
MN
01
—
800084
PREFERRED ONE
MN
01
—
84-57408
MEDICA
MN
Enumeration date
09/27/2006
Last updated
04/10/2008
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