Provider Demographics
NPI:1013660174
Name:EISENBERG, SUSAN CAROL (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:EISENBERG
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 1:35 E MAIN ST STE 125
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3845
Mailing Address - Country:US
Mailing Address - Phone:860-325-7344
Mailing Address - Fax:
Practice Address - Street 1:35 E MAIN ST STE 125
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3845
Practice Address - Country:US
Practice Address - Phone:860-325-7344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-30
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty