Provider Demographics
NPI:1063190130
Name:GREENWADE, EBONY (LMT, MMP)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:GREENWADE
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 SICKLE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-1338
Mailing Address - Country:US
Mailing Address - Phone:317-938-9028
Mailing Address - Fax:
Practice Address - Street 1:1060 E 86TH ST STE 61H
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1831
Practice Address - Country:US
Practice Address - Phone:317-296-5348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21806682225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist