Provider Demographics
NPI:1285030486
Name:GREEN, EBONY (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 E MARY LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1453
Mailing Address - Country:US
Mailing Address - Phone:210-701-4806
Mailing Address - Fax:
Practice Address - Street 1:501 W RAY RD STE 1-2
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-7284
Practice Address - Country:US
Practice Address - Phone:480-296-2363
Practice Address - Fax:480-685-9875
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-15
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2355S0801X, 235Z00000X
AZAZSLP11463235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant