Provider Demographics
NPI:1932071628
Name:SMITH, EBONY RENEE
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:RENEE
Last Name:SMITH
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 1:4308 GEORGE FRYE CIR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5774
Mailing Address - Country:US
Mailing Address - Phone:760-717-0319
Mailing Address - Fax:
Practice Address - Street 1:14011 WORTH AVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4123
Practice Address - Country:US
Practice Address - Phone:703-792-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701015335101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health