Provider Demographics
NPI:1033466230
Name:VAPOREAN-BUSSEY-PAYNE, EBONY CHANTAL (MFT)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:CHANTAL
Last Name:VAPOREAN-BUSSEY-PAYNE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:CHANTAL
Other - Last Name:CASTLEBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3420 KENYON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5001
Mailing Address - Country:US
Mailing Address - Phone:877-496-0450
Mailing Address - Fax:
Practice Address - Street 1:3420 KENYON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5001
Practice Address - Country:US
Practice Address - Phone:774-968-0450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76691106H00000X
390200000X
CA93244106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program