Provider Demographics
NPI:1780178145
Name:ALLEN, EBONY RAE
Entity type:Individual
Prefix:MISS
First Name:EBONY
Middle Name:RAE
Last Name:ALLEN
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 1:1133 S JEFFERSON ST APT 9
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-3888
Mailing Address - Country:US
Mailing Address - Phone:614-596-6364
Mailing Address - Fax:
Practice Address - Street 1:1133 S JEFFERSON ST APT 9
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-3888
Practice Address - Country:US
Practice Address - Phone:614-596-6364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212614224Z00000X
OHOTA005619224Z00000X
PAOP009723224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1780178145Medicaid