Provider Demographics
NPI:1255857306
Name:EBORN, EARLEY III
Entity type:Individual
Prefix:
First Name:EARLEY
Middle Name:
Last Name:EBORN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 1ST ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-1763
Mailing Address - Country:US
Mailing Address - Phone:202-518-7207
Mailing Address - Fax:
Practice Address - Street 1:1400 1ST ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-1763
Practice Address - Country:US
Practice Address - Phone:202-518-7207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCSLP001114235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist