Provider Demographics
NPI:1902267289
Name:GOLDEN, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 LAKEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4150
Mailing Address - Country:US
Mailing Address - Phone:786-348-5044
Mailing Address - Fax:
Practice Address - Street 1:123 SESAMEE STREET
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4150
Practice Address - Country:US
Practice Address - Phone:786-487-6342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008824101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional