Provider Demographics
NPI:1073667531
Name:EBENSTEIN, NOEMI (PHD)
Entity Type:Individual
Prefix:DR
First Name:NOEMI
Middle Name:
Last Name:EBENSTEIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:NOEMI
Other - Middle Name:
Other - Last Name:EBENSTEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:23020 COVENTRY WOODS LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2041
Mailing Address - Country:US
Mailing Address - Phone:248-356-6229
Mailing Address - Fax:
Practice Address - Street 1:21650 WESL ELEVEN MILE ROAD
Practice Address - Street 2:SUITE 209
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3777
Practice Address - Country:US
Practice Address - Phone:248-910-9291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002033103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F34655Medicare ID - Type UnspecifiedPROVIDER NO