Provider Demographics
NPI:1619577251
Name:EWELL, SHAKIRAH
Entity Type:Individual
Prefix:
First Name:SHAKIRAH
Middle Name:
Last Name:EWELL
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 1:4075 LINGLESTOWN RD # 172
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-1020
Mailing Address - Country:US
Mailing Address - Phone:862-414-2214
Mailing Address - Fax:
Practice Address - Street 1:100 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401
Practice Address - Country:US
Practice Address - Phone:862-414-2214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC014624P101YM0800X
NJ37PC00759900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619577251OtherNPI 1