Provider Demographics
NPI:1972309904
Name:GIBSON, EBONY LACHE
Entity type:Individual
Prefix:MS
First Name:EBONY
Middle Name:LACHE
Last Name:GIBSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10530 CAMPUS WAY S STE 1223
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1309
Mailing Address - Country:US
Mailing Address - Phone:888-912-5922
Mailing Address - Fax:
Practice Address - Street 1:10530 CAMPUS WAY S STE 1223
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-1309
Practice Address - Country:US
Practice Address - Phone:888-912-5922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No172V00000XOther Service ProvidersCommunity Health Worker