Basic Information
| Provider Information | |||||||||
| NPI: | 1114393212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EBERLY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCABA, LABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6013 S REDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841235220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012555131 | ||||||||
| FaxNumber: | 8012555131 | ||||||||
| Practice Location | |||||||||
| Address1: | 1858 W 5150 S | ||||||||
| Address2: | |||||||||
| City: | ROY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840673000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012555131 | ||||||||
| FaxNumber: | 8016580604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2015 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 106E00000X | 10673594-2507 | UT | Y | 193200000X MULTI-SPECIALTY GROUP |
No ID Information.