Provider Demographics
NPI:1912725797
Name:DEBOSE-MOORE, EBONYE DAWN (LPC)
Entity type:Individual
Prefix:
First Name:EBONYE
Middle Name:DAWN
Last Name:DEBOSE-MOORE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 FAIRFAX CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4240
Mailing Address - Country:US
Mailing Address - Phone:601-672-6943
Mailing Address - Fax:
Practice Address - Street 1:731 S PEAR ORCHARD RD STE 51
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4841
Practice Address - Country:US
Practice Address - Phone:601-981-0725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2070101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health