Provider Demographics
NPI:1235363367
Name:EISENGA, TONI LEONA
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:LEONA
Last Name:EISENGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 N EL DORADO ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1305
Mailing Address - Country:US
Mailing Address - Phone:209-468-2337
Mailing Address - Fax:
Practice Address - Street 1:1149 N EL DORADO ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1305
Practice Address - Country:US
Practice Address - Phone:209-468-2337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC0986642101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC0986642OtherDRIVERS LICENSE