MEDICARE: EBONY GRIFFIN

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	101YM0800X	Mental Health Counselor	LGP8286	MD
2	101Y00000X	Counselor	LC10853	MD

General Provider Information

NPI Number	:	1578024766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY GRIFFIN

Provider Business Mailing Address
First Line	:	9672 MARLBORO PIKE
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-3767
Country	:	US
Telephone Number	:	301-965-2303
Fax Number	:

Provider Business Practice Location Address
First Line	:	9672 MARLBORO PIKE
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-3767
Country	:	US
Telephone Number	:	301-965-2303
Fax Number	:

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

Provider Enumeration Date	:	03/29/2019
Last Update Date	:	04/06/2022

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Directions to “ EBONY GRIFFIN ” Practice Location

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