Provider Demographics
NPI:1194964932
Name:LUSSIER, EILEEN (PHD)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:LUSSIER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:C FASOLI
Other - Last Name:LUSSIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1325 E CHURCH ST
Mailing Address - Street 2:207, MAILBOX 12
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5909
Mailing Address - Country:US
Mailing Address - Phone:805-904-0399
Mailing Address - Fax:805-614-5843
Practice Address - Street 1:1325 E CHURCH ST
Practice Address - Street 2:207, MAILBOX 12
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5909
Practice Address - Country:US
Practice Address - Phone:805-904-0399
Practice Address - Fax:805-614-5843
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2012-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19249103TA0400X, 103TA0700X, 103TB0200X, 103TC0700X, 103TH0100X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACE386ZMedicare UPIN