Provider Demographics
NPI:1922533686
Name:EASTHAM, ALISSA D (LCSW)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:D
Last Name:EASTHAM
Suffix:
Gender:F
Credentials:LCSW
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 32
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47701-0032
Mailing Address - Country:US
Mailing Address - Phone:812-853-9110
Mailing Address - Fax:812-759-9869
Practice Address - Street 1:7144 E VIRGINIA ST
Practice Address - Street 2:SUITE C
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-9125
Practice Address - Country:US
Practice Address - Phone:812-479-1242
Practice Address - Fax:812-479-1330
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006744A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34006744AOtherIN LCSW LICENSE