Healthcare Provider Details

I. General information

NPI: 1346647906
Provider Name (Legal Business Name): EMONA LASHELLE EWHAREKUKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2162 CHERRY AVE
SAINT LOUIS MO
63121-5625
US

IV. Provider business mailing address

2162 CHERRY AVE
SAINT LOUIS MO
63121-5625
US

V. Phone/Fax

Practice location:
  • Phone: 314-526-1352
  • Fax:
Mailing address:
  • Phone: 314-526-1352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberS137338040
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: