Provider Demographics
NPI:1326834391
Name:LEWIS, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:LEWIS
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 1:3609 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-4114
Mailing Address - Country:US
Mailing Address - Phone:323-298-3680
Mailing Address - Fax:213-402-3551
Practice Address - Street 1:3609 10TH AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-4114
Practice Address - Country:US
Practice Address - Phone:323-298-3680
Practice Address - Fax:213-402-3551
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 172V00000X, 373H00000X
CAMPSS-ZSPFMN175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171400000XOther Service ProvidersHealth & Wellness Coach
No172V00000XOther Service ProvidersCommunity Health Worker
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist