Basic Information
Provider Information | |||||||||
NPI: | 1114219193 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EAGON | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, CCC-A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HERZOG | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | ELLEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA, CCC-A | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3024 BUSINESS PARK CIR | ||||||||
Address2: |   | ||||||||
City: | GOODLETTSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 370723132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158516033 | ||||||||
FaxNumber: | 6158512018 | ||||||||
Practice Location | |||||||||
Address1: | 787 WEATHERLY DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CLARKSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 370438949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9316471255 | ||||||||
FaxNumber: | 9316472399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2011 | ||||||||
LastUpdateDate: | 05/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
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 | 231H00000X | A0000001259 | TN | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 1525013 | 05 | TN |   | MEDICAID | 6091991 | 01 | TN | BCBS TN | OTHER |