Provider Demographics
NPI:1922449255
Name:EBERT, CHANEL IRENE MARIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:IRENE MARIE
Last Name:EBERT
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 1:2492 WALNUT AVENUE, #140
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6953
Mailing Address - Country:US
Mailing Address - Phone:714-544-2188
Mailing Address - Fax:714-544-2189
Practice Address - Street 1:2492 WALNUT AVENUE, #140
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6953
Practice Address - Country:US
Practice Address - Phone:714-544-2188
Practice Address - Fax:714-544-2189
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2617225100000X
CAPT41213225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist