Provider Demographics
NPI:1245569896
Name:TABANAO, EBONY (RPT)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:TABANAO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3290 N RIDGE RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3655
Mailing Address - Country:US
Mailing Address - Phone:413-557-8020
Mailing Address - Fax:410-750-0787
Practice Address - Street 1:1 LOVE LN
Practice Address - Street 2:
Practice Address - City:SOUTH DENNIS
Practice Address - State:MA
Practice Address - Zip Code:02660-3445
Practice Address - Country:US
Practice Address - Phone:413-557-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist