Basic Information
| Provider Information | |||||||||
| NPI: | 1770717118 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EAGEN | ||||||||
| FirstName: | MELISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1741 ASHLAND AVE | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256564215 | ||||||||
| FaxNumber: | 4256565075 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N. BROADWAY | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439239200 | ||||||||
| FaxNumber: | 4256565075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2009 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT00004515 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.