Provider Demographics
NPI:1376636647
Name:EWEN, IDA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:IDA
Middle Name:MARIE
Last Name:EWEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6410 SPYGLASS LN
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-1707
Mailing Address - Country:US
Mailing Address - Phone:941-484-5431
Mailing Address - Fax:941-727-8005
Practice Address - Street 1:901 VENETIA BAY BLVD
Practice Address - Street 2:SUITE 358
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-8041
Practice Address - Country:US
Practice Address - Phone:941-484-5431
Practice Address - Fax:941-727-8005
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2009-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00005326103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59801OtherBLUE CROSS BLUE SHIELD ID