Provider Demographics
NPI:1144770579
Name:HARTWELL, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:HARTWELL
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 1:5412 BOULDER HWY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-6039
Mailing Address - Country:US
Mailing Address - Phone:702-291-7121
Mailing Address - Fax:
Practice Address - Street 1:5412 BOULDER HWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-6039
Practice Address - Country:US
Practice Address - Phone:702-291-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health