Healthcare Provider Details

I. General information

NPI: 1003142670
Provider Name (Legal Business Name): ELLEN SCHLOSSBERG EISEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2009
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7710 WOLF RIVER CIR
GERMANTOWN TN
38138-1734
US

IV. Provider business mailing address

7710 WOLF RIVER CIR
GERMANTOWN TN
38138-1734
US

V. Phone/Fax

Practice location:
  • Phone: 901-685-5969
  • Fax: 901-681-0306
Mailing address:
  • Phone: 901-685-5969
  • Fax: 901-681-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW3826
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC5883
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: