Healthcare Provider Details

I. General information

NPI: 1093304289
Provider Name (Legal Business Name): KENNETH MICHAEL EATON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 3RD AVE
CHESAPEAKE OH
45619-1036
US

IV. Provider business mailing address

2210 9TH AVE
HUNTINGTON WV
25703-1806
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-1455
  • Fax:
Mailing address:
  • Phone: 304-942-9054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.186451
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: