Healthcare Provider Details

I. General information

NPI: 1326834391
Provider Name (Legal Business Name): EBONY LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 10TH AVE
LOS ANGELES CA
90018-4114
US

IV. Provider business mailing address

3609 10TH AVE
LOS ANGELES CA
90018-4114
US

V. Phone/Fax

Practice location:
  • Phone: 323-298-3680
  • Fax: 213-402-3551
Mailing address:
  • Phone: 323-298-3680
  • Fax: 213-402-3551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-ZSPFMN
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: