Provider Demographics
NPI:1679996532
Name:EWING, KELLY (MED)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:EWING
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:PURPURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:448 LAKESHORE PKWY
Mailing Address - Street 2:NORTHLAKE II, SUITE 205
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-4264
Mailing Address - Country:US
Mailing Address - Phone:803-329-3177
Mailing Address - Fax:
Practice Address - Street 1:1906 HIGHWAY 521 BYP S
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-7579
Practice Address - Country:US
Practice Address - Phone:803-285-1456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health