Healthcare Provider Details

I. General information

NPI: 1699611574
Provider Name (Legal Business Name): EBONY NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14631 IRVING AVE
DOLTON IL
60419-2027
US

IV. Provider business mailing address

14631 IRVING AVE
DOLTON IL
60419-2027
US

V. Phone/Fax

Practice location:
  • Phone: 312-366-1458
  • Fax:
Mailing address:
  • Phone: 312-366-1458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number150.129038
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: