MEDICARE: DR. AMY JO EIERMANN PH.D., NCSP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6352000102	MI
2	103TC0700X	Clinical Psychologist	071.010957	IL

General Provider Information

NPI Number	:	1417572181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY JO EIERMANN PH.D., NCSP

Provider Business Mailing Address
First Line	:	1913 W 19TH ST UNIT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2647
Country	:	US
Telephone Number	:	231-534-4341
Fax Number	:

Provider Business Practice Location Address
First Line	:	1913 W 19TH ST UNIT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2647
Country	:	US
Telephone Number	:	231-534-4341
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2020
Last Update Date	:	07/12/2024

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