Basic Information
| Provider Information | |||||||||
| NPI: | 1235851601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KITTRELL | ||||||||
| FirstName: | EBONIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 308 VICTOR PL APT 4L | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274061779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364586868 | ||||||||
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| Practice Location | |||||||||
| Address1: | 229 TURNER DR | ||||||||
| Address2: | |||||||||
| City: | REIDSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273205736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363492233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2022 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P018269 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.