Provider Demographics
NPI:1821619685
Name:LOVE, EBONY NICOLE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:NICOLE
Last Name:LOVE
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 1:1300 LOCUST ST # STC
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-1366
Mailing Address - Country:US
Mailing Address - Phone:417-448-9766
Mailing Address - Fax:816-265-1828
Practice Address - Street 1:1300 LOCUST ST # STC
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-1366
Practice Address - Country:US
Practice Address - Phone:417-448-9766
Practice Address - Fax:816-265-1828
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician