Provider Demographics
NPI:1295994564
Name:GOULBOURNE, EBONIE S
Entity type:Individual
Prefix:
First Name:EBONIE
Middle Name:S
Last Name:GOULBOURNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 ASYLUM AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2416
Mailing Address - Country:US
Mailing Address - Phone:860-548-0030
Mailing Address - Fax:
Practice Address - Street 1:999 ASYLUM AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2416
Practice Address - Country:US
Practice Address - Phone:860-548-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker