Provider Demographics
NPI:1568518470
Name:EBBAH, AGNES L
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:L
Last Name:EBBAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28004 S WESTERN AVE
Mailing Address - Street 2:APT 310
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-1200
Mailing Address - Country:US
Mailing Address - Phone:310-910-5280
Mailing Address - Fax:
Practice Address - Street 1:28004 S WESTERN AVE
Practice Address - Street 2:APT 310
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-1200
Practice Address - Country:US
Practice Address - Phone:310-910-5280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA01230500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist