Provider Demographics
NPI:1295101368
Name:COOMBS, EBONI
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:
Last Name:COOMBS
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 1:141 OLD ORANGE PARK RD APT 152
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-3029
Mailing Address - Country:US
Mailing Address - Phone:413-657-4790
Mailing Address - Fax:
Practice Address - Street 1:141 OLD ORANGE PARK RD APT 152
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-3029
Practice Address - Country:US
Practice Address - Phone:413-657-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18463OtherBLUE CROSS BLUE SHIELD
MA1307576Medicaid
MA1303295Medicaid
MA1307576Medicaid