Basic Information
| Provider Information | |||||||||
| NPI: | 1447567870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EBATA | ||||||||
| FirstName: | GLADYS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27374 STATE HIGHWAY 21 | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546604501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083725819 | ||||||||
| FaxNumber: | 6083720889 | ||||||||
| Practice Location | |||||||||
| Address1: | 27374 STATE HIGHWAY 21 | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546604501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083725819 | ||||||||
| FaxNumber: | 6083720889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 09/07/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4364 - 123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.