Healthcare Provider Details

I. General information

NPI: 1356054324
Provider Name (Legal Business Name): EBONY C COGBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8411 BROADWAY AVE
CLEVELAND OH
44105-3932
US

IV. Provider business mailing address

9521 GRAND DIVISION AVE APT 2
CLEVELAND OH
44125-1451
US

V. Phone/Fax

Practice location:
  • Phone: 216-441-0200
  • Fax:
Mailing address:
  • Phone: 216-298-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: