Provider Demographics
NPI:1992402655
Name:EBERHARDT, SHANE T (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:T
Last Name:EBERHARDT
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 W AGENCY RD
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1667
Mailing Address - Country:US
Mailing Address - Phone:319-768-5858
Mailing Address - Fax:
Practice Address - Street 1:400 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-9407
Practice Address - Country:US
Practice Address - Phone:319-768-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG173329363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health