Healthcare Provider Details

I. General information

NPI: 1245186592
Provider Name (Legal Business Name): EBONY NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 BALTIMORE NATIONAL PIKE STE 170A-204
BALTIMORE MD
21228-3930
US

IV. Provider business mailing address

1131 HOLLINS ST
BALTIMORE MD
21223-2555
US

V. Phone/Fax

Practice location:
  • Phone: 443-435-4282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34230
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: