MEDICARE: EBONY GUMS LICSW

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	1041C0700X	Clinical Social Worker	22523	MN
2	1041C0700X	Clinical Social Worker	SWI.LW.61505637	WA

General Provider Information

NPI Number	:	1841800315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY GUMS LICSW

Provider Business Mailing Address
First Line	:	1544 GREENWOOD CT N
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-1306
Country	:	US
Telephone Number	:	612-310-2873
Fax Number	:

Provider Business Practice Location Address
First Line	:	1544 GREENWOOD CT N
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55122-1306
Country	:	US
Telephone Number	:	612-310-2873
Fax Number	:

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

Provider Enumeration Date	:	08/08/2020
Last Update Date	:	05/07/2026

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Directions to “ EBONY GUMS LICSW” Practice Location

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