Provider Demographics
NPI:1235259342
Name:EISENHAUER, LORI MICHELLE (MS LCPC)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:MICHELLE
Last Name:EISENHAUER
Suffix:
Gender:F
Credentials:MS LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 DUIS RD
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:IL
Mailing Address - Zip Code:62849-1936
Mailing Address - Country:US
Mailing Address - Phone:618-323-9835
Mailing Address - Fax:618-323-9835
Practice Address - Street 1:206 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3902
Practice Address - Country:US
Practice Address - Phone:618-533-6672
Practice Address - Fax:618-533-6675
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20158940OtherFIN