Provider Demographics
NPI:1881694321
Name:EISENBERGER, KENNETH (LICSW, DCSW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:EISENBERGER
Suffix:
Gender:M
Credentials:LICSW, DCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17183 CLEAR CREEK RD NW
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7225
Mailing Address - Country:US
Mailing Address - Phone:360-626-1457
Mailing Address - Fax:360-626-1457
Practice Address - Street 1:1303 S O ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98363-1218
Practice Address - Country:US
Practice Address - Phone:360-626-1457
Practice Address - Fax:360-626-1457
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000052181041C0700X, 1041C0700X
CALCS 270201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8511768Medicaid
WAG8902184OtherMEDICARE