Healthcare Provider Details

I. General information

NPI: 1669099602
Provider Name (Legal Business Name): EBONI NIKIA VERNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 S BLUE ISLAND AVE STE 1
CHICAGO IL
60608-2238
US

IV. Provider business mailing address

1622 S BLUE ISLAND AVE STE 1
CHICAGO IL
60608-2238
US

V. Phone/Fax

Practice location:
  • Phone: 312-584-0559
  • Fax:
Mailing address:
  • Phone: 312-584-0559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-41566
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: