Provider Demographics
NPI:1871760397
Name:GIDDINS VAUGHAN, EBONY SAMARA (LCSW-C)
Entity type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:SAMARA
Last Name:GIDDINS VAUGHAN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3839 JANBROOK RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2705
Mailing Address - Country:US
Mailing Address - Phone:410-382-4536
Mailing Address - Fax:
Practice Address - Street 1:9199 REISTERSTOWN RD STE 204B
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4593
Practice Address - Country:US
Practice Address - Phone:410-382-4536
Practice Address - Fax:410-655-1329
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD126661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical