Provider Demographics
NPI:1457093189
Name:EATON, ADRIAN CARL (PSR CLASSROOM INST)
Entity Type:Individual
Prefix:MR
First Name:ADRIAN
Middle Name:CARL
Last Name:EATON
Suffix:
Gender:M
Credentials:PSR CLASSROOM INST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N DUSTIN AVE APT 327
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2143
Mailing Address - Country:US
Mailing Address - Phone:505-386-9026
Mailing Address - Fax:
Practice Address - Street 1:1001 W BROADWAY STE D&E
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-327-4796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty