Provider Demographics
NPI:1124443767
Name:EWING, BRENT
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:EWING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-1620
Mailing Address - Country:US
Mailing Address - Phone:740-418-2426
Mailing Address - Fax:
Practice Address - Street 1:445 SHAWNEE LN
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-4145
Practice Address - Country:US
Practice Address - Phone:740-779-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06886225200000X
CA10317225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant