Provider Demographics
NPI:1346621273
Name:EASTMAN, JUSTIN
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:EASTMAN
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:PO BOX 17509
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96151-7509
Mailing Address - Country:US
Mailing Address - Phone:530-541-4594
Mailing Address - Fax:530-542-1200
Practice Address - Street 1:2494 LAKE TAHOE BLVD
Practice Address - Street 2:SUITE B6
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7719
Practice Address - Country:US
Practice Address - Phone:530-541-4594
Practice Address - Fax:530-542-1200
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR931014101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)