Provider Demographics
NPI:1558968842
Name:EISEN, ETHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:EISEN
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 1:107 LAKESIDE DR E
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1718
Mailing Address - Country:US
Mailing Address - Phone:516-259-3148
Mailing Address - Fax:
Practice Address - Street 1:107 LAKESIDE DR E
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1718
Practice Address - Country:US
Practice Address - Phone:516-259-3148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05837103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical