Provider Demographics
NPI:1609243765
Name:EBBERT, MICHALENE MARIE (MA,LPCALPSRTT-S)
Entity Type:Individual
Prefix:MRS
First Name:MICHALENE
Middle Name:MARIE
Last Name:EBBERT
Suffix:
Gender:F
Credentials:MA,LPCALPSRTT-S
Other - Prefix:MRS
Other - First Name:MICHALENE
Other - Middle Name:MARIE
Other - Last Name:PETRAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:218 D ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-3104
Mailing Address - Country:US
Mailing Address - Phone:304-201-2095
Mailing Address - Fax:304-204-2096
Practice Address - Street 1:234 LEE AVE
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-2304
Practice Address - Country:US
Practice Address - Phone:304-201-2095
Practice Address - Fax:304-201-2096
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV836101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor