Basic Information
| Provider Information | |||||||||
| NPI: | 1376843284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EISELE | ||||||||
| FirstName: | HEATHER | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8170 MCCORMICK BLVD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476730718 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8170 MCCORMICK BLVD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476730718 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0004X | 071.007975 | IL | N | Behavioral Health & Social Service Providers | Psychologist | Health | 103T00000X | 071007975 | IL | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 071007975 | 01 | IL | LICENSE | OTHER |