Basic Information
| Provider Information | |||||||||
| NPI: | 1063643906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EGGLETON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 511 MORRIS ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043410511 | ||||||||
| FaxNumber: | 3046971286 | ||||||||
| Practice Location | |||||||||
| Address1: | 511 MORRIS ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043410511 | ||||||||
| FaxNumber: | 3046971286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 07/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CP00452036 | WV | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0005355002 | 05 | WV | MEDICAID |