Provider Demographics
NPI:1114393212
Name:EBERLY, LISA (BCABA, LABA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:EBERLY
Suffix:
Gender:F
Credentials:BCABA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6013 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5220
Mailing Address - Country:US
Mailing Address - Phone:801-255-5131
Mailing Address - Fax:801-255-5131
Practice Address - Street 1:1858 W 5150 S
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-3000
Practice Address - Country:US
Practice Address - Phone:801-255-5131
Practice Address - Fax:801-658-0604
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT10673594-2507106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor