Provider Demographics
NPI:1417548215
Name:FADIS, EBONY L
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:L
Last Name:FADIS
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 1:1747 OLENTANGY RIVER RD # 1030
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-1453
Mailing Address - Country:US
Mailing Address - Phone:614-843-4210
Mailing Address - Fax:
Practice Address - Street 1:943 ROBERSON ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-3645
Practice Address - Country:US
Practice Address - Phone:614-843-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No172V00000XOther Service ProvidersCommunity Health Worker