Provider Demographics
NPI:1164757902
Name:EBERLY, MARIAN C (RN, LCSW)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:C
Last Name:EBERLY
Suffix:
Gender:F
Credentials:RN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12612 N BLACK CANYON HWY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-1345
Mailing Address - Country:US
Mailing Address - Phone:623-252-7433
Mailing Address - Fax:
Practice Address - Street 1:12612 N BLACK CANYON HWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-1345
Practice Address - Country:US
Practice Address - Phone:623-252-7433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-41271041C0700X
AZRN058888163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health