Provider Demographics
NPI:1093478364
Name:EBNER, TAMARA (CPRS/CADC INTERN)
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:
Last Name:EBNER
Suffix:
Gender:F
Credentials:CPRS/CADC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SHEEPSHEAD DR
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08757-5820
Mailing Address - Country:US
Mailing Address - Phone:732-500-6953
Mailing Address - Fax:
Practice Address - Street 1:725 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5968
Practice Address - Country:US
Practice Address - Phone:327-367-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJAD-GTL-21-02309101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1487204145Medicaid