Provider Demographics
NPI:1235368093
Name:EBERHART, KAY (MMP)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:
Last Name:EBERHART
Suffix:
Gender:F
Credentials:MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 E FERGUSON AVE
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1904
Mailing Address - Country:US
Mailing Address - Phone:618-254-2626
Mailing Address - Fax:
Practice Address - Street 1:82 E FERGUSON AVE
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1904
Practice Address - Country:US
Practice Address - Phone:618-254-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.007642225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist