Provider Demographics
NPI:1891121869
Name:RAO, EBONY A (LAC)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:A
Last Name:RAO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:
Other - Last Name:KEITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2743 FOREST GROVE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1034
Mailing Address - Country:US
Mailing Address - Phone:732-640-4739
Mailing Address - Fax:
Practice Address - Street 1:11330 VANSTORY DR
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078
Practice Address - Country:US
Practice Address - Phone:980-494-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-22
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00172000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional