Healthcare Provider Details

I. General information

NPI: 1265427868
Provider Name (Legal Business Name): EBON SCOTT ALLEY LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ALDEN DR 90 MDG
FE WARREN AFB WY
82005-3906
US

IV. Provider business mailing address

7924 SIRINGO PASS
AUSTIN TX
78749-2727
US

V. Phone/Fax

Practice location:
  • Phone: 307-773-2998
  • Fax: 307-773-4721
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11902
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: