Provider Demographics
NPI:1477239556
Name:HARRELL, EBONI FAITH
Entity Type:Individual
Prefix:
First Name:EBONI
Middle Name:FAITH
Last Name:HARRELL
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 1:17478 VIOLET DR UNIT 32
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2097
Mailing Address - Country:US
Mailing Address - Phone:850-586-3717
Mailing Address - Fax:
Practice Address - Street 1:17478 VIOLET DR UNIT 32
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2097
Practice Address - Country:US
Practice Address - Phone:850-586-3717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-21-186401106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty