Provider Demographics
NPI:1780301663
Name:BELLO, EBONY (PTA)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:BELLO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:
Other - Last Name:CREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5206 KENSINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3242
Mailing Address - Country:US
Mailing Address - Phone:443-695-2705
Mailing Address - Fax:
Practice Address - Street 1:5206 KENSINGTON CIR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-3242
Practice Address - Country:US
Practice Address - Phone:443-695-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004851225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty