Provider Demographics
NPI:1730236977
Name:EISENBERG, PHYLLIS TERRY II (BS RN, MEED)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:TERRY
Last Name:EISENBERG
Suffix:II
Gender:F
Credentials:BS RN, MEED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 170911
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-8081
Mailing Address - Country:US
Mailing Address - Phone:414-795-4104
Mailing Address - Fax:
Practice Address - Street 1:250 N SUNNY SLOPE RD
Practice Address - Street 2:SUITE 290
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4809
Practice Address - Country:US
Practice Address - Phone:262-754-9460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1884-125101YP2500X
WI51189-030163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39790000Medicaid