Provider Demographics
NPI:1508046699
Name:ECCLES, KAREN DIANE
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:DIANE
Last Name:ECCLES
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 1:18252 OAKBROOK LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89508-4020
Mailing Address - Country:US
Mailing Address - Phone:775-624-2882
Mailing Address - Fax:775-624-2882
Practice Address - Street 1:18252 OAKBROOK LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89508-4020
Practice Address - Country:US
Practice Address - Phone:775-624-2882
Practice Address - Fax:775-624-2882
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVGF-467290320800000X, 320900000X, 322D00000X, 323P00000X, 324500000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No385H00000XRespite Care FacilityRespite Care