Provider Demographics
NPI:1033243795
Name:EBENKAMP, LAURIE (RPT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:EBENKAMP
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 W 90TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CONWAY SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:67031-8020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CESSNA BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67215-1400
Practice Address - Country:US
Practice Address - Phone:316-517-7455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1101587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist