Provider Demographics
NPI:1285491068
Name:EATMON, GUINEVERE CASSANDRA
Entity type:Individual
Prefix:MS
First Name:GUINEVERE
Middle Name:CASSANDRA
Last Name:EATMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43422 W OAKS DR # 424
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3300
Mailing Address - Country:US
Mailing Address - Phone:313-475-4251
Mailing Address - Fax:
Practice Address - Street 1:24781 5 MILE RD # 107
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-3632
Practice Address - Country:US
Practice Address - Phone:313-475-4251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501014606225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty