Provider Demographics
NPI:1093190050
Name:EDWARDS, EBONEE PERTRICE (MS, CRC, LPCA)
Entity Type:Individual
Prefix:
First Name:EBONEE
Middle Name:PERTRICE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MS, CRC, LPCA
Other - Prefix:
Other - First Name:EBONEE
Other - Middle Name:PERTRICE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CRC, LPCA
Mailing Address - Street 1:3282 WINDING BRANCH TRL
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-6151
Mailing Address - Country:US
Mailing Address - Phone:336-970-7831
Mailing Address - Fax:
Practice Address - Street 1:1001 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3245
Practice Address - Country:US
Practice Address - Phone:336-721-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA11721101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional