=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346072162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN DALLAS EBERTH OTD, OTRL, CDP, CFPS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2024
-----------------------------------------------------
Last Update Date | 08/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3905 LORRAINE PATH
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-8630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-428-1111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 686
-----------------------------------------------------
City | SOUTH HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49090-0686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-720-7831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Occupational Therapist
-----------------------------------------------------
License Number | 5201003590
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------