Healthcare Provider Details

I. General information

NPI: 1881694321
Provider Name (Legal Business Name): KENNETH EISENBERGER LICSW, DCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 S O ST
PORT ANGELES WA
98363-1218
US

IV. Provider business mailing address

17183 CLEAR CREEK RD NW
POULSBO WA
98370-7225
US

V. Phone/Fax

Practice location:
  • Phone: 360-626-1457
  • Fax: 360-626-1457
Mailing address:
  • Phone: 360-626-1457
  • Fax: 360-626-1457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00005218
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: