Provider Demographics
NPI:1922204692
Name:EISELE, AMY PERRAS (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:PERRAS
Last Name:EISELE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 DAVIE AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-5316
Mailing Address - Country:US
Mailing Address - Phone:704-878-2227
Mailing Address - Fax:
Practice Address - Street 1:229 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5316
Practice Address - Country:US
Practice Address - Phone:704-878-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0036461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002200Medicaid