Provider Demographics
NPI:1851884720
Name:MITCHELL, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:MITCHELL
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 1:2611 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1833
Mailing Address - Country:US
Mailing Address - Phone:937-641-8554
Mailing Address - Fax:877-938-3265
Practice Address - Street 1:1020 WOODMAN DR STE 330
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1410
Practice Address - Country:US
Practice Address - Phone:937-253-0606
Practice Address - Fax:877-938-3265
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHW.20002261041S0200X
104100000X, 171M00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program