Provider Demographics
NPI:1487706172
Name:EBAUGH, JAMES ROBERT (LMSW)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ROBERT
Last Name:EBAUGH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23140 BOLAM AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-4416
Mailing Address - Country:US
Mailing Address - Phone:586-498-5875
Mailing Address - Fax:313-961-4612
Practice Address - Street 1:220 BAGLEY ST
Practice Address - Street 2:SUITE 700
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-1400
Practice Address - Country:US
Practice Address - Phone:313-965-2141
Practice Address - Fax:313-961-4612
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801079240104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical