Provider Demographics
NPI:1740503820
Name:EBOLI, JOHN (MA OTR/L)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:EBOLI
Suffix:
Gender:M
Credentials:MA OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 LASALLE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-5916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2828 LASALLE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5916
Practice Address - Country:US
Practice Address - Phone:718-938-3302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012186-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist