Provider Demographics
NPI:1659600401
Name:EITZEN, JOHN BURKE (LLMSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BURKE
Last Name:EITZEN
Suffix:
Gender:M
Credentials:LLMSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 CHARTIER
Mailing Address - Street 2:#2
Mailing Address - City:MARINE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48039-2344
Mailing Address - Country:US
Mailing Address - Phone:810-765-3919
Mailing Address - Fax:
Practice Address - Street 1:156 CHARTIER
Practice Address - Street 2:#2
Practice Address - City:MARINE CITY
Practice Address - State:MI
Practice Address - Zip Code:48039-2344
Practice Address - Country:US
Practice Address - Phone:810-765-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010915571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical