Healthcare Provider Details

I. General information

NPI: 1467897728
Provider Name (Legal Business Name): EBONY STAR BAKER-MOORE EDD,LPC,MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 ALEXANDER STREET SUITE 2
DOUGLASVILLE GA
30134-7205
US

IV. Provider business mailing address

3486 MCKOWN RD
DOUGLASVILLE GA
30134-2812
US

V. Phone/Fax

Practice location:
  • Phone: 404-597-9910
  • Fax: 888-908-7984
Mailing address:
  • Phone: 404-597-9910
  • Fax: 888-908-7984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007289
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC007289
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: