Healthcare Provider Details

I. General information

NPI: 1376041582
Provider Name (Legal Business Name): EBONY MEDINA WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10601 WALKER ST STE 170
CYPRESS CA
90630-4759
US

IV. Provider business mailing address

PO BOX 128
MANHATTAN BEACH CA
90267-0128
US

V. Phone/Fax

Practice location:
  • Phone: 248-765-8679
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115599
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number125893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: