Provider Demographics
NPI:1841481744
Name:EBNER, EUGENE (PHD)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:
Last Name:EBNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29994 NORTHWESTERN HWY STE J
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3225
Mailing Address - Country:US
Mailing Address - Phone:248-851-9379
Mailing Address - Fax:248-851-8698
Practice Address - Street 1:29994 NORTHWESTERN HWY STE J
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3225
Practice Address - Country:US
Practice Address - Phone:248-851-9379
Practice Address - Fax:248-851-8698
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301000555103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF34703Medicare PIN