Provider Demographics
NPI:1194463265
Name:EBONG, AMIRA GRACE (DPT)
Entity type:Individual
Prefix:
First Name:AMIRA
Middle Name:GRACE
Last Name:EBONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 TACOMA MALL BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-6828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:663 JORDAN ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4748
Practice Address - Country:US
Practice Address - Phone:318-222-8892
Practice Address - Fax:318-222-8893
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
LACP039153T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist