Provider Demographics
NPI:1942432018
Name:EISMAN, ELLEN M (PHD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:M
Last Name:EISMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 NW YOSEMITE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6628
Mailing Address - Country:US
Mailing Address - Phone:541-385-3155
Mailing Address - Fax:541-388-5110
Practice Address - Street 1:1012 SW EMKAY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1010
Practice Address - Country:US
Practice Address - Phone:541-385-3155
Practice Address - Fax:541-388-5110
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR913103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR106324Medicare UPIN