Healthcare Provider Details

I. General information

NPI: 1629788500
Provider Name (Legal Business Name): EBONY NICOLE BRYANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 WILMINGTON AVE STE 2B
LOS ANGELES CA
90059-3019
US

IV. Provider business mailing address

12021 WILMINGTON AVE STE 2B
LOS ANGELES CA
90059-3019
US

V. Phone/Fax

Practice location:
  • Phone: 310-221-6336
  • Fax:
Mailing address:
  • Phone: 310-221-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT137414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: