Healthcare Provider Details

I. General information

NPI: 1346072162
Provider Name (Legal Business Name): STEVEN DALLAS EBERTH OTD, OTRL, CDP, CFPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 LORRAINE PATH
SAINT JOSEPH MI
49085-8630
US

IV. Provider business mailing address

PO BOX 686
SOUTH HAVEN MI
49090-0686
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-1111
  • Fax:
Mailing address:
  • Phone: 269-720-7831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number5201003590
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: