Provider Demographics
NPI:1609557081
Name:JOHNSON, EBONIE
Entity Type:Individual
Prefix:
First Name:EBONIE
Middle Name:
Last Name:JOHNSON
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 1:6061 COLONIAL PKWY UNIT 9204
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36542-5503
Mailing Address - Country:US
Mailing Address - Phone:251-225-1075
Mailing Address - Fax:
Practice Address - Street 1:6061 COLONIAL PKWY UNIT 9204
Practice Address - Street 2:
Practice Address - City:GULF SHORES
Practice Address - State:AL
Practice Address - Zip Code:36542-5503
Practice Address - Country:US
Practice Address - Phone:251-225-1075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5402C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical