Provider Demographics
NPI:1124441662
Name:EBERT, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:EBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6109 AFTON PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-8313
Mailing Address - Country:US
Mailing Address - Phone:323-461-4118
Mailing Address - Fax:323-461-4119
Practice Address - Street 1:6109 AFTON PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-8313
Practice Address - Country:US
Practice Address - Phone:323-461-4118
Practice Address - Fax:323-461-4119
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00317065101YM0800X
CA20101YP2500X
CALPCC3987101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health