Provider Demographics
NPI:1447567870
Name:EBATA, GLADYS (LCSW)
Entity type:Individual
Prefix:MS
First Name:GLADYS
Middle Name:
Last Name:EBATA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27374 STATE HIGHWAY 21
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-4501
Mailing Address - Country:US
Mailing Address - Phone:608-372-5819
Mailing Address - Fax:608-372-0889
Practice Address - Street 1:27374 STATE HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-4501
Practice Address - Country:US
Practice Address - Phone:608-372-5819
Practice Address - Fax:608-372-0889
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4364 - 1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical