Provider Demographics
NPI:1730816471
Name:EBERSOLE, MARY ELLEN
Entity type:Individual
Prefix:MRS
First Name:MARY ELLEN
Middle Name:
Last Name:EBERSOLE
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 1:11038 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-2816
Mailing Address - Country:US
Mailing Address - Phone:301-704-0882
Mailing Address - Fax:
Practice Address - Street 1:10632 LITTLE PATUXENT PKWY STE 441
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-6260
Practice Address - Country:US
Practice Address - Phone:410-720-4245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDE01074174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist