Provider Demographics
NPI:1871711697
Name:EBERT, STEPHEN GERARD (SLP)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:GERARD
Last Name:EBERT
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 LEWIS AVE S
Mailing Address - Street 2:STE 210
Mailing Address - City:WATERTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55388-4500
Mailing Address - Country:US
Mailing Address - Phone:952-955-2242
Mailing Address - Fax:952-955-2010
Practice Address - Street 1:2060 UPPER 55TH ST E
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55077-1725
Practice Address - Country:US
Practice Address - Phone:952-955-2242
Practice Address - Fax:952-955-2010
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5782235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP43123OtherHEALTH PARTNERS
MN20F98EBOtherBCBS MN