Provider Demographics
NPI:1073368783
Name:MANZANO, EBONY LAUREN (LSW)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:LAUREN
Last Name:MANZANO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-0053
Mailing Address - Country:US
Mailing Address - Phone:201-772-8417
Mailing Address - Fax:
Practice Address - Street 1:9541 JULIAN CLARK AVE STE 208
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3486
Practice Address - Country:US
Practice Address - Phone:704-796-9037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06985900104100000X
NJ017399931041S0200X
NCP0204291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool