MEDICARE: CHRIS EATON MFT INTERN

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	106H00000X	Marriage & Family Therapist	IMF 51388	CA

General Provider Information

NPI Number	:	1730396169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRIS EATON MFT INTERN

Provider Business Mailing Address
First Line	:	2945 MCMILLAN AVE
Second Line	:	SUITE 136
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-6766
Country	:	US
Telephone Number	:	805-781-4757
Fax Number	:	805-781-1267

Provider Business Practice Location Address
First Line	:	2945 MCMILLAN AVE
Second Line	:	SUITE 136
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-6766
Country	:	US
Telephone Number	:	805-781-4757
Fax Number	:	805-781-1267

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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