=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245504802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINDA EBERT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2012
-----------------------------------------------------
Last Update Date | 02/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 433 HARRISON AVENUE
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-774-1592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7716 BETTY LOUISE DR
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32404-8536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-774-1592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MRS. LINDA CAROL EBERT
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 850-774-1592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW9223
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------