Provider Demographics
NPI:1346072162
Name:EBERTH, STEVEN DALLAS (OTD, OTRL, CDP, CFPS)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:DALLAS
Last Name:EBERTH
Suffix:
Gender:M
Credentials:OTD, OTRL, CDP, CFPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-0686
Mailing Address - Country:US
Mailing Address - Phone:269-720-7831
Mailing Address - Fax:
Practice Address - Street 1:3905 LORRAINE PATH
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8630
Practice Address - Country:US
Practice Address - Phone:269-428-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003590225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology