Provider Demographics
NPI:1679173108
Name:EBONY THERAPY LLC
Entity Type:Organization
Organization Name:EBONY THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICIAL DELEGATE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:GENINE
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:314-791-2606
Mailing Address - Street 1:3751 PENNRIDGE DR STE 119
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-1244
Mailing Address - Country:US
Mailing Address - Phone:314-443-7776
Mailing Address - Fax:314-735-4377
Practice Address - Street 1:3751 PENNRIDGE DR STE 119
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-1244
Practice Address - Country:US
Practice Address - Phone:314-791-2606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-26
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty