Basic Information
| Provider Information | |||||||||
| NPI: | 1700442589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EIBEN | ||||||||
| FirstName: | THEODOR | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1662 MARS AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441073825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162823838 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1662 MARS AVE # 103 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441073825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162823838 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.2002702 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.