Provider Demographics
NPI:1598870438
Name:EISENBERG, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:EISENBERG
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 1:95 CHASE RUN
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-3558
Mailing Address - Country:US
Mailing Address - Phone:781-436-3404
Mailing Address - Fax:
Practice Address - Street 1:251 CAUSEWAY ST
Practice Address - Street 2:ROOM 229
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2148
Practice Address - Country:US
Practice Address - Phone:617-248-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2148103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist