Provider Demographics
NPI:1558989285
Name:EBERSBERGER, RYAN JAMES (LCSW-A)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:EBERSBERGER
Suffix:
Gender:M
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7667
Mailing Address - Country:US
Mailing Address - Phone:541-930-5611
Mailing Address - Fax:
Practice Address - Street 1:2830 MAPLE CT
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-1357
Practice Address - Country:US
Practice Address - Phone:541-830-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL127471041C0700X
NCP0128751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1558989285Medicaid