Provider Demographics
NPI:1629518675
Name:STEPHENS, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:STEPHENS
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 1:13524 MANN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-2438
Mailing Address - Country:US
Mailing Address - Phone:216-482-8839
Mailing Address - Fax:
Practice Address - Street 1:13524 MANN AVE
Practice Address - Street 2:
Practice Address - City:EAST CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112
Practice Address - Country:US
Practice Address - Phone:216-482-8839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401090920510376K00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No376K00000XNursing Service Related ProvidersNurse's Aide