Provider Demographics
NPI:1467690693
Name:EBERT, EDWARD H (PMHNP)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:H
Last Name:EBERT
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-353-9494
Mailing Address - Fax:360-353-9440
Practice Address - Street 1:15455 65TH AVE S
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188
Practice Address - Country:US
Practice Address - Phone:360-353-9494
Practice Address - Fax:360-353-9440
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60499640363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health