Provider Demographics
NPI:1154706356
Name:BRUSHBREAKER, EBONY C (LCSW)
Entity type:Individual
Prefix:MS
First Name:EBONY
Middle Name:C
Last Name:BRUSHBREAKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 S ABALONE DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-7401
Mailing Address - Country:US
Mailing Address - Phone:702-427-4537
Mailing Address - Fax:
Practice Address - Street 1:7390 W SAHARA AVE STE 240
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2764
Practice Address - Country:US
Practice Address - Phone:702-427-4537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10879-C1041C0700X
104100000X
AZLCSW-217901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV20144064283Medicaid