Healthcare Provider Details

I. General information

NPI: 1619293362
Provider Name (Legal Business Name): TOM A. EISENBERG, PH.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 HUNTINGTON DR #306
SOUTH PASADENA CA
91030-4964
US

IV. Provider business mailing address

PO BOX 327
TEMPLE CITY CA
91780-0327
US

V. Phone/Fax

Practice location:
  • Phone: 626-799-3869
  • Fax: 626-768-7490
Mailing address:
  • Phone: 626-799-3869
  • Fax: 626-768-7490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY20136
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS18694
License Number StateCA

VIII. Authorized Official

Name: DR. TOM ANDREW EISENBERG
Title or Position: CLINICAL DIRECTOR
Credential: PH.D.
Phone: 626-799-3869