Healthcare Provider Details

I. General information

NPI: 1841800315
Provider Name (Legal Business Name): EBONY GUMS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2020
Last Update Date: 08/08/2020
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 NICOLLET AVE
MINNEAPOLIS MN
55419-2560
US

IV. Provider business mailing address

515 BEECH ST
WATERLOO IA
50703-3317
US

V. Phone/Fax

Practice location:
  • Phone: 612-323-1040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22523
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: