Provider Demographics
NPI:1235663931
Name:EWING, MICHELE
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:EWING
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 1:2626 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MARINERS PLAZA DR STE 603
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-6826
Practice Address - Country:US
Practice Address - Phone:985-465-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA721469692Medicaid