Provider Demographics
NPI:1093304289
Name:EATON, KENNETH MICHAEL
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:EATON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1806
Mailing Address - Country:US
Mailing Address - Phone:304-942-9054
Mailing Address - Fax:
Practice Address - Street 1:517 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619-1036
Practice Address - Country:US
Practice Address - Phone:740-451-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVCDCA.186451101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)