Provider Demographics
NPI:1699402826
Name:EASTMAN, KELLY MARIE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:LIKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLPC, NCC
Mailing Address - Street 1:930 RIDGEVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-3441
Mailing Address - Country:US
Mailing Address - Phone:586-260-6641
Mailing Address - Fax:
Practice Address - Street 1:3069 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2324
Practice Address - Country:US
Practice Address - Phone:586-260-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health