Provider Demographics
NPI:1235285354
Name:EBY, MARY L
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:L
Last Name:EBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 MCMASTERS AVE
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-2244
Mailing Address - Country:US
Mailing Address - Phone:573-221-1258
Mailing Address - Fax:573-221-2994
Practice Address - Street 1:4650 MCMASTERS AVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-2244
Practice Address - Country:US
Practice Address - Phone:573-221-1258
Practice Address - Fax:573-221-2994
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004305225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO004305OtherLICENSE