Provider Demographics
NPI:1508320912
Name:EICKELBECK, ETELKA
Entity Type:Individual
Prefix:MS
First Name:ETELKA
Middle Name:
Last Name:EICKELBECK
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 1:69 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10560-1311
Mailing Address - Country:US
Mailing Address - Phone:914-703-2008
Mailing Address - Fax:
Practice Address - Street 1:69 LAKE ST
Practice Address - Street 2:
Practice Address - City:NORTH SALEM
Practice Address - State:NY
Practice Address - Zip Code:10560-1311
Practice Address - Country:US
Practice Address - Phone:914-703-2008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004482225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty