Provider Demographics
NPI:1699002204
Name:EBAUGH, LISA (MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:EBAUGH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 BENFIELD BLVD
Mailing Address - Street 2:SUITE J
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-2639
Mailing Address - Country:US
Mailing Address - Phone:410-987-2031
Mailing Address - Fax:410-987-4710
Practice Address - Street 1:1110 BENFIELD BLVD
Practice Address - Street 2:SUITE J
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-2639
Practice Address - Country:US
Practice Address - Phone:410-987-2031
Practice Address - Fax:410-987-4710
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist