Provider Demographics
NPI:1437161205
Name:RICH, EBONY L (LCSW)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:L
Last Name:RICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:
Other - Last Name:SCHUMPERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-9365
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:2600 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-1533
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:574-537-2652
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004869A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000490641OtherANTHEM PIN