Provider Demographics
NPI:1487080412
Name:EISENHARDT, CORINNE
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:EISENHARDT
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 1:1910 HILLHURST AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-2712
Mailing Address - Country:US
Mailing Address - Phone:818-660-5862
Mailing Address - Fax:
Practice Address - Street 1:1910 HILLHURST AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2712
Practice Address - Country:US
Practice Address - Phone:818-660-5862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0017294101YM0800X
MI6401013640101YM0800X
CA4467101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4467OtherLICENSE PROFESSIONAL CLINICAL COUNSELOR
MI6401013640OtherLICENSED PROFESSIONAL COUNSELOR
CO0017294OtherSTATE LICENSING BOARD