Provider Demographics
NPI:1306555073
Name:PETERMAN, EBONY WHITE (OTR/L, CLT)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:WHITE
Last Name:PETERMAN
Suffix:
Gender:F
Credentials:OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10512 TEA OLIVE CIR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140-4528
Mailing Address - Country:US
Mailing Address - Phone:804-687-3140
Mailing Address - Fax:
Practice Address - Street 1:241 MCLAWS CIR STE 105
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5861
Practice Address - Country:US
Practice Address - Phone:757-503-9665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004514225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119004514OtherVIRGINIA LICENSE