Healthcare Provider Details

I. General information

NPI: 1588012934
Provider Name (Legal Business Name): EBONY Y GYABAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 INTERSTATE DR STE 3
WEST SPRINGFIELD MA
01089-5100
US

IV. Provider business mailing address

181 MASSASOIT ST
SPRINGFIELD MA
01107-1756
US

V. Phone/Fax

Practice location:
  • Phone: 413-330-0415
  • Fax:
Mailing address:
  • Phone: 413-330-0415
  • Fax: 413-733-7841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1120753
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: