Provider Demographics
NPI:1689820185
Name:EBERHARDT, RENEE S (LMT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:S
Last Name:EBERHARDT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3022 W MATTHEW DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-2364
Mailing Address - Country:US
Mailing Address - Phone:623-243-6925
Mailing Address - Fax:
Practice Address - Street 1:34406 N 27TH DR
Practice Address - Street 2:BLDG 2, SUITE 108
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6082
Practice Address - Country:US
Practice Address - Phone:623-266-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-11488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist