Provider Demographics
NPI:1336418037
Name:EISEN, FRED I (MA)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:I
Last Name:EISEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 AUBINWOOD RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-1690
Mailing Address - Country:US
Mailing Address - Phone:413-253-5071
Mailing Address - Fax:
Practice Address - Street 1:180 AUBINWOOD RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-1690
Practice Address - Country:US
Practice Address - Phone:413-253-5071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-26
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1415101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral