=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659227239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILIP DAVID EISEMAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2026
-----------------------------------------------------
Last Update Date | 03/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3919 BLENHEIM BLVD STE 83B
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-691-5539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3919 BLENHEIM BLVD STE 83B
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-691-5539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0810006307
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------