Healthcare Provider Details

I. General information

NPI: 1982261368
Provider Name (Legal Business Name): ALEX KEITH EATON PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 4TH AVE. NW
MINOT ND
58703
US

IV. Provider business mailing address

1705 4TH AVE. NW
MINOT ND
58703
US

V. Phone/Fax

Practice location:
  • Phone: 701-839-0474
  • Fax: 701-839-0713
Mailing address:
  • Phone: 701-839-0474
  • Fax: 701-839-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number609
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: