Provider Demographics
NPI:1508356775
Name:EATON, MARY MELISSA (LISW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MELISSA
Last Name:EATON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 CRANSTON RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3032
Mailing Address - Country:US
Mailing Address - Phone:415-405-6310
Mailing Address - Fax:
Practice Address - Street 1:7537 MENTOR AVE STE 208
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5464
Practice Address - Country:US
Practice Address - Phone:440-299-8674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18009671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical