Provider Demographics
NPI:1477868354
Name:EBORN, DALE
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:
Last Name:EBORN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 S. TEN MILE RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84750
Mailing Address - Country:US
Mailing Address - Phone:435-326-4300
Mailing Address - Fax:435-326-4313
Practice Address - Street 1:8500 S. TEN MILE RD
Practice Address - Street 2:
Practice Address - City:MARYSVALE
Practice Address - State:UT
Practice Address - Zip Code:84750
Practice Address - Country:US
Practice Address - Phone:435-326-4300
Practice Address - Fax:435-326-4313
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No253J00000XAgenciesFoster Care Agency