Basic Information
| Provider Information | |||||||||
| NPI: | 1295339687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGESDAL | ||||||||
| FirstName: | MICHAELA | ||||||||
| MiddleName: | FAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S ILLINOIS AVE | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504015405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414283041 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 4TH ST SW | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504012800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414287000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2020 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 101457 | IA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.