Provider Demographics
NPI:1821629601
Name:EBERENZ, BRIGID MARY (DPT)
Entity Type:Individual
Prefix:
First Name:BRIGID
Middle Name:MARY
Last Name:EBERENZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BRIGID
Other - Middle Name:
Other - Last Name:GILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 FOXBANK PLANTATION BLVD STE E
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-6706
Practice Address - Country:US
Practice Address - Phone:843-761-4622
Practice Address - Fax:843-761-4625
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013702225100000X
NY0436171225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist