Basic Information
| Provider Information | |||||||||
| NPI: | 1043586092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EAGAN | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW,MSW,BSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PIERCE | ||||||||
| OtherFirstName: | CAROLINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW, MSW,BSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | WELLMORE INC-CHILDRENS SERVICES | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035750466 | ||||||||
| FaxNumber: | 2035751827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2012 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 008242 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 008049710 | 05 | CT | MEDICAID | 060669107 | 01 | CT | UBH/OXFORD HEALTH LIBERTY/FREEDOM WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | OPTUM BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | MHN TRICARENORTH WELLMORE | OTHER | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH-WELLMORE | OTHER | 060669107 | 01 | CT | UBH/UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER | CAQH | 01 | CT | 12656269 | OTHER | PENDING | 01 | CT | MHN MANAGED HEALTH NETWORK- WELLMORE | OTHER | 060669107 | 01 | CT | UBH/CONNECTICARE WELLMORE GRP/FACILITY | OTHER | D339123- 141 E MAIN | 01 | CT | BEACON HEALTH STRATEGIES | OTHER |