Provider Demographics
NPI:1164439568
Name:EWING, COLLEEN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:A
Last Name:EWING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7794
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-0294
Mailing Address - Country:US
Mailing Address - Phone:917-533-5714
Mailing Address - Fax:
Practice Address - Street 1:3900 MONUMENT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3955
Practice Address - Country:US
Practice Address - Phone:804-340-5565
Practice Address - Fax:804-340-5577
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003538103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist