Provider Demographics
NPI:1225901382
Name:EBERHART, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EBERHART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17195 CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1415
Mailing Address - Country:US
Mailing Address - Phone:574-277-0274
Mailing Address - Fax:
Practice Address - Street 1:17195 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1415
Practice Address - Country:US
Practice Address - Phone:574-277-0274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34011337A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health