Provider Demographics
NPI:1790828150
Name:EWING, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:EWING
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 1:529 QUINNIPIAC AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-4004
Mailing Address - Country:US
Mailing Address - Phone:203-887-4345
Mailing Address - Fax:203-503-3297
Practice Address - Street 1:400 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3250
Practice Address - Fax:203-503-3297
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004820104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0040399533Medicaid