Healthcare Provider Details

I. General information

NPI: 1043878556
Provider Name (Legal Business Name): SHELBY EBERSTEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23770 HOSPITAL ST
CASSOPOLIS MI
49031-9644
US

IV. Provider business mailing address

14088 S 30TH ST
VICKSBURG MI
49097-9502
US

V. Phone/Fax

Practice location:
  • Phone: 269-445-3801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502005857
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: