Provider Demographics
NPI:1194937227
Name:EWING, MARTIN KYEL (LCPC)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:KYEL
Last Name:EWING
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7724 S. CORNELL AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649
Mailing Address - Country:US
Mailing Address - Phone:773-307-6511
Mailing Address - Fax:
Practice Address - Street 1:8704 S. CONSTANCE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617
Practice Address - Country:US
Practice Address - Phone:773-734-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health