Healthcare Provider Details

I. General information

NPI: 1952125809
Provider Name (Legal Business Name): EBANYSANGEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 OLDE TOWNE WAY UNIT 4
MYRTLE BEACH SC
29588-1502
US

IV. Provider business mailing address

172 OLDE TOWNE WAY UNIT 4
MYRTLE BEACH SC
29588-1502
US

V. Phone/Fax

Practice location:
  • Phone: 509-864-0860
  • Fax:
Mailing address:
  • Phone: 509-864-0860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. NICHOLE LYNN NOLAN
Title or Position: CLINICAL SOCIAL WORKER
Credential: LICSW
Phone: 509-864-0860