Provider Demographics
NPI:1043866619
Name:EBNER, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:EBNER
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 1:3606 BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:THOMPSONS STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37179-9739
Mailing Address - Country:US
Mailing Address - Phone:615-477-1771
Mailing Address - Fax:
Practice Address - Street 1:1601 6TH ST SE STE B
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4605
Practice Address - Country:US
Practice Address - Phone:863-294-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist