MEDICARE: KELLY MARIE EASTMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1699402826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MARIE EASTMAN

Provider Business Mailing Address
First Line	:	930 RIDGEVIEW CIR
Second Line	:
City	:	LAKE ORION
State	:	MI
Zip	:	48362-3441
Country	:	US
Telephone Number	:	586-260-6641
Fax Number	:

Provider Business Practice Location Address
First Line	:	3069 UNIVERSITY DR
Second Line	:
City	:	AUBURN HILLS
State	:	MI
Zip	:	48326-2324
Country	:	US
Telephone Number	:	586-260-6641
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2022
Last Update Date	:	08/08/2022

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