Provider Demographics
NPI:1063436657
Name:EICHORN, MARY ANN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:EICHORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 N PROSPECT RD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-6451
Mailing Address - Country:US
Mailing Address - Phone:309-679-1700
Mailing Address - Fax:309-679-0703
Practice Address - Street 1:4700 N PROSPECT RD
Practice Address - Street 2:SUITE A-1
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-6451
Practice Address - Country:US
Practice Address - Phone:309-679-1700
Practice Address - Fax:309-679-0703
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical