Healthcare Provider Details

I. General information

NPI: 1447966106
Provider Name (Legal Business Name): JOSHUA KIETH EAVES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6316 CHERYLWOOD DR APT D
SPRINGFIELD IL
62712-7591
US

IV. Provider business mailing address

6316 CHERYLWOOD DR APT D
SPRINGFIELD IL
62712-7591
US

V. Phone/Fax

Practice location:
  • Phone: 217-408-8727
  • Fax:
Mailing address:
  • Phone: 217-408-8727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.025128
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: