Provider Demographics
NPI:1659430775
Name:BROWN, EBONY NICOLE (BA EXP PSYCHOLOGY RN)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:NICOLE
Last Name:BROWN
Suffix:
Gender:F
Credentials:BA EXP PSYCHOLOGY RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3009
Mailing Address - Country:US
Mailing Address - Phone:864-585-0366
Mailing Address - Fax:864-585-9208
Practice Address - Street 1:250 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3009
Practice Address - Country:US
Practice Address - Phone:864-585-0366
Practice Address - Fax:864-585-9208
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC106396163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1427168889Medicaid
SC3335Medicare UPIN