Provider Demographics
NPI:1366838617
Name:EATON, KELSEY SUE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:SUE
Last Name:EATON
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 1:5253 BAMBURG CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-2822
Mailing Address - Country:US
Mailing Address - Phone:240-529-8977
Mailing Address - Fax:301-695-9694
Practice Address - Street 1:65 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE A
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4371
Practice Address - Country:US
Practice Address - Phone:301-662-3808
Practice Address - Fax:301-695-9694
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician