Provider Demographics
NPI:1669509733
Name:EISENBERG, TOM ANDREW (PHD)
Entity Type:Individual
Prefix:DR
First Name:TOM
Middle Name:ANDREW
Last Name:EISENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-0327
Mailing Address - Country:US
Mailing Address - Phone:626-799-3869
Mailing Address - Fax:626-768-7490
Practice Address - Street 1:2130 HUNTINGTON DR
Practice Address - Street 2:#306
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4964
Practice Address - Country:US
Practice Address - Phone:626-799-3869
Practice Address - Fax:626-768-7490
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20136103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY201360Medicaid