Provider Demographics
NPI:1376270033
Name:EBNETER, MELISSA BROOKE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:BROOKE
Last Name:EBNETER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3688 KINNARD DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30360-1504
Mailing Address - Country:US
Mailing Address - Phone:404-861-8733
Mailing Address - Fax:
Practice Address - Street 1:3688 KINNARD DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30360-1504
Practice Address - Country:US
Practice Address - Phone:404-861-8733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0065721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty