Healthcare Provider Details

I. General information

NPI: 1740140458
Provider Name (Legal Business Name): EOS PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2025
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 MARION CT
CLINTON MI
49236-9749
US

IV. Provider business mailing address

413 MARION CT
CLINTON MI
49236-9749
US

V. Phone/Fax

Practice location:
  • Phone: 812-598-6911
  • Fax:
Mailing address:
  • Phone: 812-598-6911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KAITLIN ELIZABETH MOORE
Title or Position: OWNER
Credential: LPC
Phone: 812-598-6911