Provider Demographics
NPI:1992174817
Name:COAKLEY, EBONE (LCSW)
Entity type:Individual
Prefix:
First Name:EBONE
Middle Name:
Last Name:COAKLEY
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 1:519 HARMONYVIEW CT
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6233
Mailing Address - Country:US
Mailing Address - Phone:770-355-6073
Mailing Address - Fax:770-913-8027
Practice Address - Street 1:1840 OLD NORCROSS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8803
Practice Address - Country:US
Practice Address - Phone:770-355-6073
Practice Address - Fax:770-913-8027
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0048561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003168454BMedicaid
GA003168454BMedicaid