Provider Demographics
NPI:1225896558
Name:STURM, KEATON EUGENE
Entity Type:Individual
Prefix:
First Name:KEATON
Middle Name:EUGENE
Last Name:STURM
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 1:1666 E KITCHEN RD
Mailing Address - Street 2:
Mailing Address - City:PINCONNING
Mailing Address - State:MI
Mailing Address - Zip Code:48650-7480
Mailing Address - Country:US
Mailing Address - Phone:989-326-5933
Mailing Address - Fax:
Practice Address - Street 1:1666 E KITCHEN RD
Practice Address - Street 2:
Practice Address - City:PINCONNING
Practice Address - State:MI
Practice Address - Zip Code:48650-7480
Practice Address - Country:US
Practice Address - Phone:989-326-5933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS365465237757106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician