Provider Demographics
NPI:1508392234
Name:EBERLY, CHRISTINA ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ANN
Last Name:EBERLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 W SANDRA LEE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4954
Mailing Address - Country:US
Mailing Address - Phone:651-983-5664
Mailing Address - Fax:
Practice Address - Street 1:51 W SANDRA LEE DR
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4954
Practice Address - Country:US
Practice Address - Phone:651-983-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN190521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical