Provider Demographics
NPI:1033142518
Name:EIDEN, TODD C (PHD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:C
Last Name:EIDEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3229
Mailing Address - Country:US
Mailing Address - Phone:920-657-1780
Mailing Address - Fax:920-657-1784
Practice Address - Street 1:3120 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3229
Practice Address - Country:US
Practice Address - Phone:920-657-1780
Practice Address - Fax:920-657-1784
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39784300Medicaid