Provider Demographics
NPI:1346647906
Name:EWHAREKUKO, EMONA LASHELLE
Entity Type:Individual
Prefix:
First Name:EMONA
Middle Name:LASHELLE
Last Name:EWHAREKUKO
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 1:2162 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-5625
Mailing Address - Country:US
Mailing Address - Phone:314-526-1352
Mailing Address - Fax:
Practice Address - Street 1:2162 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-5625
Practice Address - Country:US
Practice Address - Phone:314-526-1352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOS137338040103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO47-1693183Medicaid
MO47-1693138Medicaid
MO47-1693183OtherBLUE CROSS, BLUE SHIELD, AETNA, KAISER-PERMANENTE, ETC