Provider Demographics
NPI:1972350098
Name:WASHINGTON, EBONY ROSE (RIC)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:ROSE
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:RIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 KARL LINN DR APT 118
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-6985
Mailing Address - Country:US
Mailing Address - Phone:912-667-3206
Mailing Address - Fax:
Practice Address - Street 1:2500 POCOSHOCK PL STE 301
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-6345
Practice Address - Country:US
Practice Address - Phone:912-667-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704015921101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor