Provider Demographics
NPI:1528129814
Name:EICKMEYER, MARY L (PSYD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:EICKMEYER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 LASKER LN
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-5342
Mailing Address - Country:US
Mailing Address - Phone:707-206-1039
Mailing Address - Fax:707-540-6276
Practice Address - Street 1:8609 LASKER LN
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-5342
Practice Address - Country:US
Practice Address - Phone:707-206-1039
Practice Address - Fax:707-540-6276
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23192103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical