Healthcare Provider Details

I. General information

NPI: 1972621332
Provider Name (Legal Business Name): SHERRI J. EBETINO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 MAGNOLIA WAY
AUGUSTA GA
30909
US

IV. Provider business mailing address

3624 J DEWEY GRAY CIR SUITE 308
AUGUSTA GA
30909-6584
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-7529
  • Fax: 706-312-7610
Mailing address:
  • Phone: 706-210-7529
  • Fax: 706-312-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA002231
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: