Provider Demographics
NPI:1821183088
Name:TEN EYCK, THEODORE C II (LICSW)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:C
Last Name:TEN EYCK
Suffix:II
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MECHANIC ST STE 2
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-4021
Mailing Address - Country:US
Mailing Address - Phone:508-543-2133
Mailing Address - Fax:774-215-5541
Practice Address - Street 1:30 MECHANIC ST STE 2
Practice Address - Street 2:
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035-4021
Practice Address - Country:US
Practice Address - Phone:508-543-2133
Practice Address - Fax:774-215-5541
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110928104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPZZ751Medicare ID - Type Unspecified