Provider Demographics
NPI:1467741942
Name:EWALT, ABBEY KRISTINE (LPC)
Entity Type:Individual
Prefix:
First Name:ABBEY
Middle Name:KRISTINE
Last Name:EWALT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 GRAND RIVER ANX
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-5312
Mailing Address - Country:US
Mailing Address - Phone:810-220-8192
Mailing Address - Fax:810-220-0402
Practice Address - Street 1:2060 GRAND RIVER ANX
Practice Address - Street 2:SUITE 600
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-5312
Practice Address - Country:US
Practice Address - Phone:810-220-8192
Practice Address - Fax:810-220-0402
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012003101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional