Provider Demographics
NPI:1750944468
Name:MAXIE, EBONY M
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:M
Last Name:MAXIE
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 1:143 E 105TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-4726
Mailing Address - Country:US
Mailing Address - Phone:310-386-7919
Mailing Address - Fax:
Practice Address - Street 1:2501 W EL SEGUNDO BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-3317
Practice Address - Country:US
Practice Address - Phone:323-754-2816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)