Healthcare Provider Details

I. General information

NPI: 1124947791
Provider Name (Legal Business Name): EBONY MALTIDA GRAYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1958 GARIBALDI AVE
CHARLOTTE NC
28208-5047
US

IV. Provider business mailing address

1958 GARIBALDI AVE
CHARLOTTE NC
28208-5047
US

V. Phone/Fax

Practice location:
  • Phone: 704-537-7775
  • Fax:
Mailing address:
  • Phone: 704-537-7775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP023711
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: