Provider Demographics
NPI:1427002211
Name:SEYBOLD, ERIC D (PHD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:D
Last Name:SEYBOLD
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 1:12630 W NORTH AVE
Mailing Address - Street 2:BLDG E
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4626
Mailing Address - Country:US
Mailing Address - Phone:262-785-1008
Mailing Address - Fax:262-432-9059
Practice Address - Street 1:12690 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4636
Practice Address - Country:US
Practice Address - Phone:262-785-1008
Practice Address - Fax:262-785-0644
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2494-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39769500Medicaid