MEDICARE: EBONY COLUMBUS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1376362228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY COLUMBUS

Provider Business Mailing Address
First Line	:	238 HOLDERNESS ST SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30314-3013
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4191 PLEASANT HILL RD
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-1411
Country	:	US
Telephone Number	:	470-444-4194
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2024
Last Update Date	:	10/08/2024

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Directions to “ EBONY COLUMBUS ” Practice Location

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