Provider Demographics
NPI:1700021375
Name:STAN EASTIN, ED.D., PA
Entity Type:Organization
Organization Name:STAN EASTIN, ED.D., PA
Other - Org Name:EASTIN ENTERPRISES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:EASTIN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, PA
Authorized Official - Phone:505-345-2778
Mailing Address - Street 1:320 OSUNA RD NE
Mailing Address - Street 2:BUILDING H, SUITE 4
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5952
Mailing Address - Country:US
Mailing Address - Phone:505-345-2778
Mailing Address - Fax:
Practice Address - Street 1:320 OSUNA RD NE
Practice Address - Street 2:BUILDING H, SUITE 4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5952
Practice Address - Country:US
Practice Address - Phone:505-345-2778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 447103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN0286Medicaid