Provider Demographics
NPI:1679185672
Name:EBISCH-BEAVERS, SHAYLA (RBT)
Entity Type:Individual
Prefix:
First Name:SHAYLA
Middle Name:
Last Name:EBISCH-BEAVERS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 SW PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-7902
Mailing Address - Country:US
Mailing Address - Phone:580-699-5558
Mailing Address - Fax:580-699-5559
Practice Address - Street 1:3005 SW PARK AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-7902
Practice Address - Country:US
Practice Address - Phone:580-699-5558
Practice Address - Fax:580-699-5559
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-20-122667106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKRBT-20-122667OtherBACB BOARD