Provider Demographics
NPI:1093752313
Name:EATON, MARC W (PHD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:W
Last Name:EATON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4524
Mailing Address - Country:US
Mailing Address - Phone:912-283-6629
Mailing Address - Fax:912-283-5980
Practice Address - Street 1:1227 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4524
Practice Address - Country:US
Practice Address - Phone:912-283-6629
Practice Address - Fax:912-283-5980
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000673103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000212726CMedicaid
GAR12499Medicare UPIN