Provider Demographics
NPI:1760787303
Name:EASTMAN, KATIE A (LPC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:A
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:GRAND LAKE
Mailing Address - State:CO
Mailing Address - Zip Code:80447-0903
Mailing Address - Country:US
Mailing Address - Phone:970-531-0501
Mailing Address - Fax:970-887-2293
Practice Address - Street 1:191 E. AGATE AVENUE
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CO
Practice Address - Zip Code:80446
Practice Address - Country:US
Practice Address - Phone:970-531-0501
Practice Address - Fax:970-887-2293
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11384101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional