Provider Demographics
NPI:1477282051
Name:COLEY, EBONIE (MS CCC- SLP)
Entity Type:Individual
Prefix:
First Name:EBONIE
Middle Name:
Last Name:COLEY
Suffix:
Gender:F
Credentials:MS CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 WESTON ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-3715
Mailing Address - Country:US
Mailing Address - Phone:919-729-7330
Mailing Address - Fax:
Practice Address - Street 1:615 COLISEUM DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-5310
Practice Address - Country:US
Practice Address - Phone:336-579-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13898235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist