Healthcare Provider Details

I. General information

NPI: 1033466230
Provider Name (Legal Business Name): EBONY CHANTAL VAPOREAN-BUSSEY-PAYNE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EBONY CHANTAL CASTLEBERRY

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 KENYON ST
SAN DIEGO CA
92110-5001
US

IV. Provider business mailing address

3420 KENYON ST
SAN DIEGO CA
92110-5001
US

V. Phone/Fax

Practice location:
  • Phone: 774-968-0450
  • Fax:
Mailing address:
  • Phone: 877-496-0450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number76691
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number93244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: