Provider Demographics
NPI:1669967089
Name:BLACKMON, EBONY LASHA
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:LASHA
Last Name:BLACKMON
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 1:3308 REHOBETH CHURCH RD APT Q
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-5038
Mailing Address - Country:US
Mailing Address - Phone:336-987-9895
Mailing Address - Fax:
Practice Address - Street 1:1401 E 7TH ST STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-6301
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician