Healthcare Provider Details

I. General information

NPI: 1518739804
Provider Name (Legal Business Name): EBONY T YEARBY MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EBONY TRISTICE YEARBY MS

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/30/2023
Certification Date: 10/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 KATHY STREET
DAYTONA BEACH FL FL
32114
US

IV. Provider business mailing address

110 LEXINGTON GREEN LN
SANFORD FL
32771-1025
US

V. Phone/Fax

Practice location:
  • Phone: 386-898-7971
  • Fax:
Mailing address:
  • Phone: 407-734-1273
  • 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: