Provider Demographics
NPI:1699354720
Name:OLIVER, EBONY (PTA)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 N GARLAND AVE APT 61
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-1920
Mailing Address - Country:US
Mailing Address - Phone:434-579-0184
Mailing Address - Fax:
Practice Address - Street 1:8267 ELMBROOK DR STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4051
Practice Address - Country:US
Practice Address - Phone:832-320-3193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
TX2160648225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant