Provider Demographics
NPI:1508371865
Name:CHARLESTON, EBONY LATREACE (QBHP)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:LATREACE
Last Name:CHARLESTON
Suffix:
Gender:F
Credentials:QBHP
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:L
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:110 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3362
Mailing Address - Country:US
Mailing Address - Phone:479-967-5570
Mailing Address - Fax:479-890-5364
Practice Address - Street 1:3240 STERMER ROAD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-327-1701
Practice Address - Fax:501-329-5508
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator