Provider Demographics
NPI:1023553385
Name:EWING, SHADORIE ANNE (CCMA)
Entity Type:Individual
Prefix:
First Name:SHADORIE
Middle Name:ANNE
Last Name:EWING
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14644 HUBBELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-4809
Mailing Address - Country:US
Mailing Address - Phone:313-282-8447
Mailing Address - Fax:
Practice Address - Street 1:14644 HUBBELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-4809
Practice Address - Country:US
Practice Address - Phone:313-282-8447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIZ5H7G8R8405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional