Provider Demographics
NPI:1598443442
Name:EBERT, ALYSSA MARIE (LDO)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:EBERT
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 POSSUM RUN RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-9447
Mailing Address - Country:US
Mailing Address - Phone:419-756-7295
Mailing Address - Fax:419-756-7574
Practice Address - Street 1:2485 POSSUM RUN RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9447
Practice Address - Country:US
Practice Address - Phone:419-756-7295
Practice Address - Fax:419-756-7574
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017026-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician