Provider Demographics
NPI:1194884304
Name:EISENBERG, GARY M (PHD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:EISENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 GLADES RD
Mailing Address - Street 2:SUITE 1-A
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6401
Mailing Address - Country:US
Mailing Address - Phone:561-392-1414
Mailing Address - Fax:561-391-2722
Practice Address - Street 1:950 GLADES RD
Practice Address - Street 2:SUITE 1-A
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6401
Practice Address - Country:US
Practice Address - Phone:561-392-1414
Practice Address - Fax:561-391-2722
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2170103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical