Provider Demographics
NPI:1275001232
Name:EANES, WEDNESDAY VELOURIA
Entity Type:Individual
Prefix:MISS
First Name:WEDNESDAY
Middle Name:VELOURIA
Last Name:EANES
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 1:4865 S SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-6836
Mailing Address - Country:US
Mailing Address - Phone:575-921-1714
Mailing Address - Fax:
Practice Address - Street 1:12650 E BRIARWOOD AVE UNIT 207
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-6792
Practice Address - Country:US
Practice Address - Phone:720-470-0578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO$$$$$$$$$OtherSOCIAL SECURITY