Provider Demographics
NPI: | 1821079476 |
---|---|
Name: | EATON-STULL, YVONNE MARIE |
Entity Type: | Individual |
Prefix: | |
First Name: | YVONNE |
Middle Name: | MARIE |
Last Name: | EATON-STULL |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | YVONNE |
Other - Middle Name: | MARIE |
Other - Last Name: | EATON |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 1330 W 26TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | ERIE |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 16508-1402 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 814-459-9300 |
Mailing Address - Fax: | 814-451-2280 |
Practice Address - Street 1: | 1330 W 26TH ST |
Practice Address - Street 2: | |
Practice Address - City: | ERIE |
Practice Address - State: | PA |
Practice Address - Zip Code: | 16508-1402 |
Practice Address - Country: | US |
Practice Address - Phone: | 814-459-9300 |
Practice Address - Fax: | 814-451-2280 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-11-10 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | CW007937L | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 7975200 | Other | AETNA |
PA | 056165 | Other | HIGHMARK KHPW |
PA | 2199747 | Other | CIGNA |
PA | 463477 | Other | VALUEOPTIONS |
PA | 2199747 | Other | CIGNA |
PA | 7975200 | Other | AETNA |