Basic Information
| Provider Information | |||||||||
| NPI: | 1245569896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TABANAO | ||||||||
| FirstName: | EBONY | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3290 N RIDGE RD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210433655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135578020 | ||||||||
| FaxNumber: | 4107500787 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 LOVE LN | ||||||||
| Address2: | |||||||||
| City: | SOUTH DENNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026603445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135578020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2009 | ||||||||
| LastUpdateDate: | 12/10/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 18102 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.