Provider Demographics
NPI:1538630231
Name:EWING, FELICIA K (LCPC)
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:K
Last Name:EWING
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4509 N ILLINOIS ST STE 5
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1524
Mailing Address - Country:US
Mailing Address - Phone:618-702-9147
Mailing Address - Fax:
Practice Address - Street 1:4509 N ILLINOIS ST STE 5
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1524
Practice Address - Country:US
Practice Address - Phone:618-702-9147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.013516101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1932506748Medicaid