Healthcare Provider Details

I. General information

NPI: 1376843284
Provider Name (Legal Business Name): HEATHER EISELE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 09/16/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8170 MCCORMICK BLVD SUITE 204
SKOKIE IL
60076-2961
US

IV. Provider business mailing address

8170 MCCORMICK BLVD SUITE 204
SKOKIE IL
60076-2961
US

V. Phone/Fax

Practice location:
  • Phone: 847-673-0718
  • Fax:
Mailing address:
  • Phone: 847-673-0718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071007975
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number071.007975
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: