Provider Demographics
NPI:1568489102
Name:EATMON, MICHAEL RAY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RAY
Last Name:EATMON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 MAXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47711
Mailing Address - Country:US
Mailing Address - Phone:812-422-7974
Mailing Address - Fax:812-422-8163
Practice Address - Street 1:2015 MAXWELL AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47711
Practice Address - Country:US
Practice Address - Phone:812-422-7974
Practice Address - Fax:812-422-8163
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001541A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN177680Medicare ID - Type Unspecified