MEDICARE: EBONY NICHOLE BLUE

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1881250934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY NICHOLE BLUE

Provider Business Mailing Address
First Line	:	11601 FIRESTONE BLVD APT 312
Second Line	:
City	:	NORWALK
State	:	CA
Zip	:	90650-8826
Country	:	US
Telephone Number	:	424-356-3301
Fax Number	:

Provider Business Practice Location Address
First Line	:	2116 S CENTRAL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-1237
Country	:	US
Telephone Number	:	213-493-4664
Fax Number	:

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

Provider Enumeration Date	:	05/14/2019
Last Update Date	:	05/14/2019

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Directions to “ EBONY NICHOLE BLUE ” Practice Location

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