Healthcare Provider Details

I. General information

NPI: 1083063887
Provider Name (Legal Business Name): EBONI CLIPPER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 QUINCE ORCHARD BLVD STE F
GAITHERSBURG MD
20878-1676
US

IV. Provider business mailing address

845 QUINCE ORCHARD BLVD STE F
GAITHERSBURG MD
20878-1676
US

V. Phone/Fax

Practice location:
  • Phone: 301-769-5878
  • Fax:
Mailing address:
  • Phone: 301-769-5878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC8459
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: