MEDICARE: EBONY GRAY BSW

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1114374865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY GRAY BSW

Provider Business Mailing Address
First Line	:	885 GOLD HILL RD # 3119
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-7946
Country	:	US
Telephone Number	:	803-493-9389
Fax Number	:

Provider Business Practice Location Address
First Line	:	885 GOLD HILL RD # 3119
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-7946
Country	:	US
Telephone Number	:	803-280-3646
Fax Number	:

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

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	03/17/2026

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