Provider Demographics
NPI:1922294552
Name:EWAN, CAROLINE MALLIKA
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:MALLIKA
Last Name:EWAN
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 1:1053 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3521
Mailing Address - Country:US
Mailing Address - Phone:909-522-4656
Mailing Address - Fax:909-763-5525
Practice Address - Street 1:1053 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3521
Practice Address - Country:US
Practice Address - Phone:909-522-4656
Practice Address - Fax:909-763-5525
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89395106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist