MEDICARE: EBONII NELSON

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	101YP2500X	Professional Counselor	77824	TX

General Provider Information

NPI Number	:	1861956633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONII NELSON

Provider Business Mailing Address
First Line	:	1100 HARWELL DR APT 1324
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-8815
Country	:	US
Telephone Number	:	469-939-6827
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 N WATSON RD STE 165
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76006-6223
Country	:	US
Telephone Number	:	469-939-6827
Fax Number	:

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

Provider Enumeration Date	:	01/25/2019
Last Update Date	:	01/25/2019

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