Provider Demographics
NPI:1124653449
Name:FAULKNER, EBONI NICOLE
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:NICOLE
Last Name:FAULKNER
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 1:7087 LITTLEBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-7066
Mailing Address - Country:US
Mailing Address - Phone:914-506-5000
Mailing Address - Fax:
Practice Address - Street 1:19 OLIVIA ST
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-4877
Practice Address - Country:US
Practice Address - Phone:914-479-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2024-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014494101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health