Provider Demographics
NPI:1922113927
Name:EASTIN, STANLEY BRENT (EDD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:BRENT
Last Name:EASTIN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 OSUNA RD NE # H
Mailing Address - Street 2: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:505-345-2878
Practice Address - Street 1:320 OSUNA RD NE # H
Practice Address - Street 2: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:505-345-2878
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 447103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN0286Medicaid