Provider Demographics
NPI:1295114734
Name:THREATT, EBONI
Entity type:Individual
Prefix:MS
First Name:EBONI
Middle Name:
Last Name:THREATT
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 1:4199 CAMPUS DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-4684
Mailing Address - Country:US
Mailing Address - Phone:949-502-4721
Mailing Address - Fax:949-502-4725
Practice Address - Street 1:2601 E CHAPMAN AVE
Practice Address - Street 2:STE. 116
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3737
Practice Address - Country:US
Practice Address - Phone:714-526-6643
Practice Address - Fax:949-502-4725
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF69809106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist