Provider Demographics
NPI:1710027073
Name:EBERSOLE, JOAN (OT)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:
Last Name:EBERSOLE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 MONTROSE DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4243
Mailing Address - Country:US
Mailing Address - Phone:678-432-4755
Mailing Address - Fax:
Practice Address - Street 1:300 EAGLES POINTE PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6384
Practice Address - Country:US
Practice Address - Phone:678-432-4755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000520225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist