Provider Demographics
NPI:1558864801
Name:MAEWEATHER, EBONY VICTORIA NICOLE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:VICTORIA NICOLE
Last Name:MAEWEATHER
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 1:2505 W SHAW AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3334
Mailing Address - Country:US
Mailing Address - Phone:559-241-7233
Mailing Address - Fax:
Practice Address - Street 1:2505 W SHAW AVE STE 2
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3334
Practice Address - Country:US
Practice Address - Phone:559-241-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18-50688106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician