Provider Demographics
NPI:1306662770
Name:EBERHADRY, ELISE JORDEN
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:JORDEN
Last Name:EBERHADRY
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 1:3722 BRIDLE RD
Mailing Address - Street 2:
Mailing Address - City:WARRENS
Mailing Address - State:WI
Mailing Address - Zip Code:54666-7610
Mailing Address - Country:US
Mailing Address - Phone:651-442-3402
Mailing Address - Fax:608-506-1114
Practice Address - Street 1:3722 BRIDLE RD
Practice Address - Street 2:
Practice Address - City:WARRENS
Practice Address - State:WI
Practice Address - Zip Code:54666-7610
Practice Address - Country:US
Practice Address - Phone:608-696-9325
Practice Address - Fax:608-506-1114
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty