Healthcare Provider Details

I. General information

NPI: 1306661533
Provider Name (Legal Business Name): EBONY STATEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19321 GROVE COMMUNITY DR
RIVERSIDE CA
92508-8113
US

IV. Provider business mailing address

19321 GROVE COMMUNITY DR
RIVERSIDE CA
92508-8113
US

V. Phone/Fax

Practice location:
  • Phone: 951-571-9096
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number143416
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number15405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: