Provider Demographics
NPI:1275181935
Name:LIBBY, EBONY JANAE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:JANAE
Last Name:LIBBY
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 1:1002 VIA LA PAZ
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2307
Mailing Address - Country:US
Mailing Address - Phone:310-985-0695
Mailing Address - Fax:
Practice Address - Street 1:713 W COMMONWEALTH AVE STE C
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1612
Practice Address - Country:US
Practice Address - Phone:714-879-4274
Practice Address - Fax:714-879-2274
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician