Provider Demographics
NPI:1093797060
Name:EUSTICE, KATIE R (LMSW-CC, CADC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:R
Last Name:EUSTICE
Suffix:
Gender:F
Credentials:LMSW-CC, CADC
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:R
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10084 DANIELS RUN WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2448
Mailing Address - Country:US
Mailing Address - Phone:303-902-0653
Mailing Address - Fax:719-314-1719
Practice Address - Street 1:10084 DANIELS RUN WAY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2448
Practice Address - Country:US
Practice Address - Phone:303-902-0653
Practice Address - Fax:719-314-1719
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099245851041C0700X
MEMC101271041C0700X
MELC113211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical