Provider Demographics
NPI:1134917818
Name:JOHNSON, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 BAILEYS RIDGE DR APT 6
Mailing Address - Street 2:
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-1457
Mailing Address - Country:US
Mailing Address - Phone:804-605-3963
Mailing Address - Fax:
Practice Address - Street 1:4601 BAILEYS RIDGE DR APT 6
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1457
Practice Address - Country:US
Practice Address - Phone:804-605-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)