Provider Demographics
NPI:1184963357
Name:MORMANT, EBONI R (LPC)
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:R
Last Name:MORMANT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:EBONI
Other - Middle Name:R
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:500 SUN VALLEY DR STE D2
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5636
Mailing Address - Country:US
Mailing Address - Phone:770-910-9162
Mailing Address - Fax:770-910-9768
Practice Address - Street 1:500 SUN VALLEY DR STE D2
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5636
Practice Address - Country:US
Practice Address - Phone:770-910-9162
Practice Address - Fax:770-910-9768
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-0011103101YP2500X
MI6401016779101YP2500X
GA006759101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional