Provider Demographics
NPI:1770895609
Name:EIGENBROD, GRETCHEN ALICE (LICAC)
Entity type:Individual
Prefix:MISS
First Name:GRETCHEN
Middle Name:ALICE
Last Name:EIGENBROD
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:MISS
Other - First Name:GRETCHEN
Other - Middle Name:ALICE
Other - Last Name:EIGENBROD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICAC
Mailing Address - Street 1:14 OLD HILLS LN
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-1013
Mailing Address - Country:US
Mailing Address - Phone:631-261-9299
Mailing Address - Fax:
Practice Address - Street 1:14 OLD HILLS LN
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740
Practice Address - Country:US
Practice Address - Phone:631-261-9299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216133171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist