Provider Demographics
NPI:1508493495
Name:VENABLE, EBONY RENE (LPT)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:RENE
Last Name:VENABLE
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3572 BANBURY DR APT 31
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1928
Mailing Address - Country:US
Mailing Address - Phone:909-361-6472
Mailing Address - Fax:909-203-7403
Practice Address - Street 1:1481 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5416
Practice Address - Country:US
Practice Address - Phone:909-361-6472
Practice Address - Fax:909-203-7403
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA34496167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician