Healthcare Provider Details

I. General information

NPI: 1457002602
Provider Name (Legal Business Name): RAPHAEL EISEMANN M.ED., BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 RIVER AVE STE 201
LAKEWOOD NJ
08701-5675
US

IV. Provider business mailing address

50 TOVA DR
LAKEWOOD NJ
08701-5650
US

V. Phone/Fax

Practice location:
  • Phone: 732-833-3723
  • Fax:
Mailing address:
  • Phone: 443-310-7609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-56901
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: