Provider Demographics
NPI:1508160565
Name:BACON, EILEEN
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:
Other - Last Name:BERK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 NEW HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:NH
Mailing Address - Zip Code:03235-2117
Mailing Address - Country:US
Mailing Address - Phone:321-202-1011
Mailing Address - Fax:
Practice Address - Street 1:41 DANIEL WEBSTER DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:NH
Practice Address - Zip Code:03235-1047
Practice Address - Country:US
Practice Address - Phone:603-931-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1326235Z00000X
FLSA10461235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist