Basic Information
| Provider Information | |||||||||
| NPI: | 1124537642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDSBY | ||||||||
| FirstName: | EBONI | ||||||||
| MiddleName: | ANICKA | ||||||||
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| Credential: | N/A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10649 EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712209685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187891978 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 506 HIGHWAY 2 | ||||||||
| Address2: | |||||||||
| City: | STERLINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185985040 | ||||||||
| FaxNumber: | 8442701958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2017 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1497113559 | 05 | LA | MEDICAID |