Provider Demographics
NPI:1962949180
Name:EISENBERG, CORRY PAYNE (LCPC)
Entity type:Individual
Prefix:
First Name:CORRY
Middle Name:PAYNE
Last Name:EISENBERG
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 S HERMITAGE AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1220
Mailing Address - Country:US
Mailing Address - Phone:503-577-4378
Mailing Address - Fax:
Practice Address - Street 1:3629 S HERMITAGE AVE
Practice Address - Street 2:APT 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1220
Practice Address - Country:US
Practice Address - Phone:503-577-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012222101YM0800X
IL178011197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health