Basic Information
| Provider Information | |||||||||
| NPI: | 1558989285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EBERSBERGER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | LCSW-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419305611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2830 MAPLE CT | ||||||||
| Address2: | |||||||||
| City: | WHITE CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975031357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418301350 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2020 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L12747 | OR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | P012875 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1558989285 | 05 | NC | MEDICAID |