Provider Demographics
NPI:1083368435
Name:EASTMAN, ELIZA ARLENE
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:ARLENE
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10310 STATE ROUTE 161 E # 1
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064-9278
Mailing Address - Country:US
Mailing Address - Phone:937-209-8012
Mailing Address - Fax:
Practice Address - Street 1:1021 CHECKREIN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-1106
Practice Address - Country:US
Practice Address - Phone:614-844-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2615030Medicaid