Provider Demographics
NPI:1316578503
Name:ADAMS, EDDY
Entity Type:Individual
Prefix:
First Name:EDDY
Middle Name:
Last Name:ADAMS
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 1:306 N KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1870
Mailing Address - Country:US
Mailing Address - Phone:312-914-0611
Mailing Address - Fax:
Practice Address - Street 1:1724 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-4819
Practice Address - Country:US
Practice Address - Phone:312-914-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician