Provider Demographics
NPI:1902537921
Name:SUTTON, EBONY (MS, EDS, LSP)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:SUTTON
Suffix:
Gender:F
Credentials:MS, EDS, LSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3946 BUTTONBUSH CIR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-3218
Mailing Address - Country:US
Mailing Address - Phone:305-505-6993
Mailing Address - Fax:
Practice Address - Street 1:1003 S ALEXANDER ST STE 3
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-8400
Practice Address - Country:US
Practice Address - Phone:813-586-1499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1373103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool