Healthcare Provider Details

I. General information

NPI: 1669052866
Provider Name (Legal Business Name): EBONY LETTINA NJIE MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8335 OFFICE PARK DR
DOUGLASVILLE GA
30134-6937
US

IV. Provider business mailing address

6570 OAKWOOD DR
DOUGLASVILLE GA
30135-1629
US

V. Phone/Fax

Practice location:
  • Phone: 678-324-0476
  • Fax:
Mailing address:
  • Phone: 404-313-2775
  • 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: