=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376410084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EBONY GRACE WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2025
-----------------------------------------------------
Last Update Date | 10/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 927 CLARKE AVE
-----------------------------------------------------
City | POCOMOKE CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21851-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-200-0953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6456 OXBRIDGE DR
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-1793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-200-0953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MRS. TINEKA CHANTEY HARMON
-----------------------------------------------------
Credential | LCSW-C
-----------------------------------------------------
Telephone | 301-524-3617
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------