Provider Demographics
NPI:1083838601
Name:EBERT, KRISTEN L (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:EBERT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 BELPAR ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3602
Mailing Address - Country:US
Mailing Address - Phone:330-493-4210
Mailing Address - Fax:330-493-4744
Practice Address - Street 1:513 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1421
Practice Address - Country:US
Practice Address - Phone:330-875-0888
Practice Address - Fax:330-875-4922
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA-01418225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant