Provider Demographics
NPI:1083864946
Name:EISDORFER, ETHAN AARON (MA)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:AARON
Last Name:EISDORFER
Suffix:
Gender:M
Credentials:MA
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:
Practice Address - Street 1:151 WORCESTER RD
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:MA
Practice Address - Zip Code:01005-9002
Practice Address - Country:US
Practice Address - Phone:978-355-6321
Practice Address - Fax:978-355-6549
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11368103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical