Provider Demographics
NPI:1881250934
Name:BLUE, EBONY NICHOLE
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:NICHOLE
Last Name:BLUE
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 1:11601 FIRESTONE BLVD APT 312
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-8826
Mailing Address - Country:US
Mailing Address - Phone:424-356-3301
Mailing Address - Fax:
Practice Address - Street 1:2116 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-1237
Practice Address - Country:US
Practice Address - Phone:213-493-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)