Provider Demographics
NPI:1063896686
Name:SMITH, EBONI TAKENDRIA
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:TAKENDRIA
Last Name:SMITH
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 1:3993 SHINAULT LANE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125
Mailing Address - Country:US
Mailing Address - Phone:901-857-9107
Mailing Address - Fax:
Practice Address - Street 1:3993 SHINAULT LN
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-2649
Practice Address - Country:US
Practice Address - Phone:901-857-9107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47 4445545171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN47 4445545OtherEIN NUMBER