Provider Demographics
NPI:1093187288
Name:EICHENBERGER, JOHN D (LMHC, CASAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:EICHENBERGER
Suffix:
Gender:M
Credentials:LMHC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CROSS KEYS OFFICE PARK
Mailing Address - Street 2:BUILDING 600 SUITE 625
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3508
Mailing Address - Country:US
Mailing Address - Phone:585-425-2840
Mailing Address - Fax:585-425-2196
Practice Address - Street 1:625 CROSS KEYS OFFICE PARK
Practice Address - Street 2:BUILDING 600 SUITE 625
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3508
Practice Address - Country:US
Practice Address - Phone:585-425-2840
Practice Address - Fax:585-425-2196
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17971101YA0400X
NY006328101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)