Healthcare Provider Details

I. General information

NPI: 1164757902
Provider Name (Legal Business Name): MARIAN C EBERLY RN, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12612 N BLACK CANYON HWY
PHOENIX AZ
85029-1345
US

IV. Provider business mailing address

12612 N BLACK CANYON HWY
PHOENIX AZ
85029-1345
US

V. Phone/Fax

Practice location:
  • Phone: 623-252-7433
  • Fax:
Mailing address:
  • Phone: 623-252-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-4127
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN058888
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: