Provider Demographics
NPI:1528123668
Name:EWELL, FONTAINE MICHELE (PHD)
Entity type:Individual
Prefix:DR
First Name:FONTAINE
Middle Name:MICHELE
Last Name:EWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W 40TH ST
Mailing Address - Street 2:THE ROTUNDA SUITE 456B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2120
Mailing Address - Country:US
Mailing Address - Phone:410-274-5911
Mailing Address - Fax:410-235-9339
Practice Address - Street 1:711 W 40TH ST
Practice Address - Street 2:THE ROTUNDA SUITE 456B
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2120
Practice Address - Country:US
Practice Address - Phone:410-274-5911
Practice Address - Fax:410-235-9339
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04047103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical