Healthcare Provider Details

I. General information

NPI: 1255748364
Provider Name (Legal Business Name): EBONY AYANA UNDERWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 MEMORIAL CIR
CLARKSVILLE TN
37043-4539
US

IV. Provider business mailing address

41521 W 11 MILE RD
NOVI MI
48375-1803
US

V. Phone/Fax

Practice location:
  • Phone: 931-920-7333
  • Fax:
Mailing address:
  • Phone: 248-912-1640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: