Provider Demographics
NPI:1891391702
Name:EPHRIAM, EBONY LECOLE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:LECOLE
Last Name:EPHRIAM
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 1:901 N SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1738
Mailing Address - Country:US
Mailing Address - Phone:719-597-0822
Mailing Address - Fax:
Practice Address - Street 1:901 N SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1738
Practice Address - Country:US
Practice Address - Phone:719-597-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician