MEDICARE: DEBORAH J EBENER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY5093	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	59612	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1124343165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEBORAH J EBENER PHD

Provider Business Mailing Address
First Line	:	1334 TIMBERLANE RD
Second Line	:	SUITE 2
City	:	TALLAHASSEE
State	:	FL
Zip	:	32312-1766
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1334 TIMBERLANE RD
Second Line	:	SUITE 2
City	:	TALLAHASSEE
State	:	FL
Zip	:	32312-1766
Country	:	US
Telephone Number	:	850-766-1669
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST / OWNER
Name	:	DR. DEBORAH J EBENER
Credential	:	PH.D.
Telephone Number	:	850-766-1669

Provider Enumeration Date	:	04/01/2010
Last Update Date	:	04/01/2010

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