Provider Demographics
NPI:1225554348
Name:GIETZEN, ERIC ANTHONY
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:ANTHONY
Last Name:GIETZEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 ROLLING PARK DRIVE NORTH
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44647
Mailing Address - Country:US
Mailing Address - Phone:330-617-7598
Mailing Address - Fax:
Practice Address - Street 1:93 ROLLING PARK DR N
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-5196
Practice Address - Country:US
Practice Address - Phone:330-617-7598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH475186391Medicaid