MEDICARE: EBONIQUA SMITH LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	104601-1	NY
2	1041C0700X	Clinical Social Worker	098623	NY

General Provider Information

NPI Number	:	1104399104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONIQUA SMITH LCSW

Provider Business Mailing Address
First Line	:	300 LENOX RD APT 5J
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-2210
Country	:	US
Telephone Number	:	646-851-7658
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 LENOX RD APT 5J
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-2210
Country	:	US
Telephone Number	:	646-851-7658
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2019
Last Update Date	:	03/02/2026

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