Provider Demographics
NPI:1457003451
Name:IRVIN, EBONY (LICSW)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:IRVIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9938 COTTONWOOD ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-5250
Mailing Address - Country:US
Mailing Address - Phone:312-647-9314
Mailing Address - Fax:
Practice Address - Street 1:7066 STILLWATER BLVD N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-3937
Practice Address - Country:US
Practice Address - Phone:312-647-9314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33018101YM0800X
IL149.024156101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health