Basic Information
| Provider Information | |||||||||
| NPI: | 1215389127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EISENHART | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 CHARLIE HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294145832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438524100 | ||||||||
| FaxNumber: | 8435732393 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 CHARLIE HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438524100 | ||||||||
| FaxNumber: | 8435732393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2016 | ||||||||
| LastUpdateDate: | 05/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 6376 | SC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 6376 | SC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 6868 | SC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1760596480 | 05 | SC | MEDICAID | 6376 | 01 | SC | LLR | OTHER |