Provider Demographics
NPI:1588020168
Name:WILLIAMS, EBONY NICOLE (TLLP)
Entity Type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:NICOLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:MS
Other - First Name:EBONY
Other - Middle Name:NICOLE
Other - Last Name:COOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TLLP
Mailing Address - Street 1:79 W ALEXANDRINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2015
Mailing Address - Country:US
Mailing Address - Phone:313-831-5535
Mailing Address - Fax:313-831-2608
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2015
Practice Address - Country:US
Practice Address - Phone:313-831-5535
Practice Address - Fax:313-831-2608
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016197103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical