Provider Demographics
NPI:1447018734
Name:SMITH, EBONIE
Entity type:Individual
Prefix:MISS
First Name:EBONIE
Middle Name:
Last Name:SMITH
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 1:12021 S. WILMINGTON BLVD
Mailing Address - Street 2:BLDG 18 STE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059
Mailing Address - Country:US
Mailing Address - Phone:985-381-0431
Mailing Address - Fax:
Practice Address - Street 1:12021 S. WILMINGTON BLVD
Practice Address - Street 2:BLDG 18 STE 301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059
Practice Address - Country:US
Practice Address - Phone:985-381-0431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)