Healthcare Provider Details

I. General information

NPI: 1578580056
Provider Name (Legal Business Name): ELIZABETH EBNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PASEO DE PERALTA
SANTA FE NM
87501-2233
US

IV. Provider business mailing address

4 RECADO RD
SANTA FE NM
87508-1917
US

V. Phone/Fax

Practice location:
  • Phone: 505-992-3117
  • Fax: 505-820-1209
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00880081
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: