Provider Demographics
NPI:1124537642
Name:GOLDSBY, EBONI ANICKA (N/A)
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:ANICKA
Last Name:GOLDSBY
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10649 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-9685
Mailing Address - Country:US
Mailing Address - Phone:318-789-1978
Mailing Address - Fax:
Practice Address - Street 1:506 HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:STERLINGTON
Practice Address - State:LA
Practice Address - Zip Code:71280
Practice Address - Country:US
Practice Address - Phone:318-598-5040
Practice Address - Fax:844-270-1958
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1497113559Medicaid