Provider Demographics
NPI:1265427868
Name:ALLEY, EBON SCOTT (LICSW)
Entity type:Individual
Prefix:
First Name:EBON
Middle Name:SCOTT
Last Name:ALLEY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7924 SIRINGO PASS
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-2727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6900 ALDEN DR
Practice Address - Street 2:90 MDG
Practice Address - City:FE WARREN AFB
Practice Address - State:WY
Practice Address - Zip Code:82005-3906
Practice Address - Country:US
Practice Address - Phone:307-773-2998
Practice Address - Fax:307-773-4721
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11902104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN