Provider Demographics
NPI:1578784302
Name:EBERT, MARYELLEN (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:
Last Name:EBERT
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 SW 12 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33134-2711
Mailing Address - Country:US
Mailing Address - Phone:786-301-7681
Mailing Address - Fax:
Practice Address - Street 1:13550 N KENDALL DR
Practice Address - Street 2:SUITE 112
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-1514
Practice Address - Country:US
Practice Address - Phone:305-383-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5736101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL761594900Medicaid