Provider Demographics
NPI:1528227477
Name:EBY, BONNIE JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:EBY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 NILES AVE
Mailing Address - Street 2:SFAC - BLDG #4973, RM 113
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314
Mailing Address - Country:US
Mailing Address - Phone:912-435-9734
Mailing Address - Fax:
Practice Address - Street 1:1145 NILES AVE
Practice Address - Street 2:SFAC - BLDG #4973, RM 113
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:912-435-9734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4981104100000X
KY33811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker