Provider Demographics
NPI:1417433855
Name:EITLAND, KRISTIN JOY
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JOY
Last Name:EITLAND
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 1:646 COUNTY ROAD NN
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WI
Mailing Address - Zip Code:54027-3810
Mailing Address - Country:US
Mailing Address - Phone:817-504-3812
Mailing Address - Fax:
Practice Address - Street 1:2201 JACK BREAULT DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-4547
Practice Address - Country:US
Practice Address - Phone:715-629-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3904-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional