Provider Demographics
NPI:1699037804
Name:EBERLINE, PHYLLIS GRIMMER (PT,DPT)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:GRIMMER
Last Name:EBERLINE
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1401
Mailing Address - Street 2:
Mailing Address - City:TAPPAHANNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22560-1401
Mailing Address - Country:US
Mailing Address - Phone:804-443-4850
Mailing Address - Fax:804-443-4851
Practice Address - Street 1:900 SOUTH CHURCH LANE
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560
Practice Address - Country:US
Practice Address - Phone:804-443-4850
Practice Address - Fax:804-443-4851
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305000880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699037804Medicaid
VA2305000880OtherVIRGINIA STATE LICENSE
VAC09695OtherGROUP MEDICARE P-TAN
VA1699037804Medicaid