Provider Demographics
NPI:1235656521
Name:MARTINEZ, EBONY (LCMHC-A)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 RIVER HWY STE D246
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-7808
Mailing Address - Country:US
Mailing Address - Phone:704-228-6103
Mailing Address - Fax:
Practice Address - Street 1:516 RIVER HWY STE D246
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-7808
Practice Address - Country:US
Practice Address - Phone:704-228-6103
Practice Address - Fax:704-368-1916
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAQASP-S9012103K00000X
GARBT-16-20302103K00000X
NCA16830101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst