Healthcare Provider Details

I. General information

NPI: 1194103119
Provider Name (Legal Business Name): EBONIE DALEY MSW, LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 SHORT ST STE 103
COLUMBUS OH
43230-3089
US

IV. Provider business mailing address

106 SHORT ST STE 103
COLUMBUS OH
43230-3089
US

V. Phone/Fax

Practice location:
  • Phone: 330-990-8760
  • Fax:
Mailing address:
  • Phone: 330-990-8760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2405774-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: