Provider Demographics
NPI:1790838639
Name:EISENBERG, GIDEON (LCSW-C)
Entity Type:Individual
Prefix:
First Name:GIDEON
Middle Name:
Last Name:EISENBERG
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5024 CAMPBELL BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-5974
Mailing Address - Country:US
Mailing Address - Phone:410-931-9280
Mailing Address - Fax:410-931-6694
Practice Address - Street 1:5024 CAMPBELL BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-5974
Practice Address - Country:US
Practice Address - Phone:410-931-9280
Practice Address - Fax:410-931-6694
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD041361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD299LB547Medicare ID - Type Unspecified
MDS12576Medicare UPIN