Provider Demographics
NPI:1588648919
Name:EBERLIN, MICHAEL B (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:EBERLIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 W MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OYSTER BAY
Mailing Address - State:NY
Mailing Address - Zip Code:11771-2258
Mailing Address - Country:US
Mailing Address - Phone:516-558-7490
Mailing Address - Fax:877-205-6740
Practice Address - Street 1:71 W MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OYSTER BAY
Practice Address - State:NY
Practice Address - Zip Code:11771-2258
Practice Address - Country:US
Practice Address - Phone:516-558-7490
Practice Address - Fax:877-205-6740
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009143-1103TC0700X
NY0985434392103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VC8431Medicare UPIN
NYV4882XZRW1Medicare UPIN