MEDICARE: KAREN R EBBERT PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2426-19	WI

General Provider Information

NPI Number	:	1487152237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN R EBBERT PTA

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1365 N PORT WASHINGTON RD
Second Line	:
City	:	GRAFTON
State	:	WI
Zip	:	53024-9333
Country	:	US
Telephone Number	:	262-474-0050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2018
Last Update Date	:	01/26/2018

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