Provider Demographics
NPI:1275978744
Name:MCEWEN, MICHELLE JANN (BA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JANN
Last Name:MCEWEN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BILLERICA AVENUE EXT UNIT 4
Mailing Address - Street 2:
Mailing Address - City:NORTH BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01862-1273
Mailing Address - Country:US
Mailing Address - Phone:978-987-8578
Mailing Address - Fax:
Practice Address - Street 1:8 BILLERICA AVENUE EXT UNIT 4
Practice Address - Street 2:
Practice Address - City:NORTH BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01862-1273
Practice Address - Country:US
Practice Address - Phone:978-987-8578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS29182611103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist