Provider Demographics
NPI:1518054279
Name:EBLEN, AIMEE LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:AIMEE
Middle Name:LYNN
Last Name:EBLEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 MILLSIDE TER
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-3256
Mailing Address - Country:US
Mailing Address - Phone:770-932-6612
Mailing Address - Fax:678-377-2833
Practice Address - Street 1:318 W PIKE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3234
Practice Address - Country:US
Practice Address - Phone:770-314-1388
Practice Address - Fax:678-377-2882
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0046632251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10037612OtherAMERIGROUP
GA00731882COtherPEACHSTATE HEALTH PLAN
GA00731882CMedicaid
GA307920OtherWELLCARE