Basic Information
| Provider Information | |||||||||
| NPI: | 1124441662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EBERT | ||||||||
| FirstName: | AMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6109 AFTON PL | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900288313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234614118 | ||||||||
| FaxNumber: | 3234614119 | ||||||||
| Practice Location | |||||||||
| Address1: | 6109 AFTON PL | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900288313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234614118 | ||||||||
| FaxNumber: | 3234614119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2014 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 00317065 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 20 | CA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | LPCC3987 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.