Basic Information
Provider Information
NPI: 1003001611
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EAGLEHAWK
FirstName: MICHELLE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: HCR 6100 BOX 30
Address2:  
City: TEECNOSPOS
State: AZ
PostalCode: 86514
CountryCode: US
TelephoneNumber: 5053686401
FaxNumber: 5053686431
Practice Location
Address1: US HWY 160 & NAVAJO ROUTE 25 - RED MESA
Address2:  
City: TEECNOSPOS
State: AZ
PostalCode: 86514
CountryCode: US
TelephoneNumber: 5053686401
FaxNumber: 5053686431
Other Information
ProviderEnumerationDate: 09/07/2007
LastUpdateDate: 02/15/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000XI-06681NMN Behavioral Health & Social Service ProvidersSocial Worker 
1041C0700XLCSW-12444AZY Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
5845932405NM MEDICAID


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