Provider Demographics
NPI:1063828598
Name:MCLEAN, EBONY MONAE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:MONAE
Last Name:MCLEAN
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 1:2963 LOMBARDY LN
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-8471
Mailing Address - Country:US
Mailing Address - Phone:951-454-9258
Mailing Address - Fax:
Practice Address - Street 1:3801 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3247
Practice Address - Country:US
Practice Address - Phone:951-454-9258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-04
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator