Provider Demographics
NPI:1871992784
Name:EBBEN, SYNTHEA J (COTA)
Entity type:Individual
Prefix:
First Name:SYNTHEA
Middle Name:J
Last Name:EBBEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157-1165
Mailing Address - Country:US
Mailing Address - Phone:715-582-0144
Mailing Address - Fax:715-582-0803
Practice Address - Street 1:701 WILLOW ST
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157-1165
Practice Address - Country:US
Practice Address - Phone:715-582-0144
Practice Address - Fax:715-582-0803
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5078225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist