Provider Demographics
NPI:1477129468
Name:EBERHARDT, MARY E
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:EBERHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:ANTHONY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:414 DIVISION DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-5109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:414 DIVISION DR
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-5109
Practice Address - Country:US
Practice Address - Phone:630-933-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.018107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist