Healthcare Provider Details

I. General information

NPI: 1902550304
Provider Name (Legal Business Name): EBONY NICOLE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2022
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2677 ZOE AVE
HUNTINGTON PARK CA
90255-4195
US

IV. Provider business mailing address

1360 S FIGUEROA ST APT 408
LOS ANGELES CA
90015-2884
US

V. Phone/Fax

Practice location:
  • Phone: 703-578-6030
  • Fax:
Mailing address:
  • Phone: 774-777-0205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: