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General NPI Number Information
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NPI Number | 1598809428
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Entity Type | Individual
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Provider Name | EBONNIE CAMILLE WEST A.T.C
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Gender | Female
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Dates
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Enumeration Date | 02/16/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 24901 NORTHWESTERN HWY
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City | SOUTHFIELD
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State | MI
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Zip | 48075-2203
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Country | US
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Telephone | 248-358-3001
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Fax |
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Provider Business Mailing Address
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Address Line | 18400 LAUDER ST
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City | DETROIT
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State | MI
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Zip | 48235-2737
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 010702102
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License Number State | NE
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