Provider Demographics
NPI:1184987554
Name:DALLAS, EBONY IMAN (MFA)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:IMAN
Last Name:DALLAS
Suffix:
Gender:F
Credentials:MFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 FOUNTAIN VW
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2618
Mailing Address - Country:US
Mailing Address - Phone:405-514-5239
Mailing Address - Fax:
Practice Address - Street 1:1920 FOUNTAIN VW
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-2618
Practice Address - Country:US
Practice Address - Phone:405-514-5239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health