Healthcare Provider Details

I. General information

NPI: 1669085379
Provider Name (Legal Business Name): SAMUEL JOSEPH ECKRICH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 01/28/2023
Certification Date: 01/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

806 STILES ST
BALTIMORE MD
21202-4318
US

V. Phone/Fax

Practice location:
  • Phone: 855-988-2273
  • Fax:
Mailing address:
  • Phone: 605-641-9272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: