Provider Demographics
NPI:1659418770
Name:EICKEN, IVERSON M (PHD)
Entity Type:Individual
Prefix:DR
First Name:IVERSON
Middle Name:M
Last Name:EICKEN
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 1:720 SOUTHPOINT BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-7495
Mailing Address - Country:US
Mailing Address - Phone:707-775-5666
Mailing Address - Fax:
Practice Address - Street 1:720 SOUTHPOINT BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-7495
Practice Address - Country:US
Practice Address - Phone:707-775-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19750103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist