Provider Demographics
NPI:1831607340
Name:EWING, PAMELA EVETTE
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:EVETTE
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 1:9145 S MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3830
Mailing Address - Country:US
Mailing Address - Phone:773-230-2166
Mailing Address - Fax:
Practice Address - Street 1:9145 S. MERRILL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617
Practice Address - Country:US
Practice Address - Phone:312-479-3007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006013101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional