Provider Demographics
NPI:1932898111
Name:BURROUGHS, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:BURROUGHS
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 1:2705 MALL OF GEORGIA BLVD APT 904
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-8734
Mailing Address - Country:US
Mailing Address - Phone:205-789-5310
Mailing Address - Fax:
Practice Address - Street 1:4319 S LEE ST STE 300
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5752
Practice Address - Country:US
Practice Address - Phone:678-288-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008574225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist