Healthcare Provider Details

I. General information

NPI: 1689820185
Provider Name (Legal Business Name): RENEE S EBERHARDT LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34406 N 27TH DR BLDG 2, SUITE 108
PHOENIX AZ
85085-6082
US

IV. Provider business mailing address

3022 W MATTHEW DR
PHOENIX AZ
85027-2364
US

V. Phone/Fax

Practice location:
  • Phone: 623-266-1700
  • Fax:
Mailing address:
  • Phone: 623-243-6925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-11488
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: