Provider Demographics
NPI:1528588571
Name:ELBERT, EBONY (CTRS)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:ELBERT
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 STANLEY RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4359
Mailing Address - Country:US
Mailing Address - Phone:770-427-0147
Mailing Address - Fax:
Practice Address - Street 1:1291 STANLEY RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4359
Practice Address - Country:US
Practice Address - Phone:770-427-0147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64872225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist