1679796718 NPI number — VIVIAN S SEWELL LCPC, NCC, OTR/L

Table of content: VIVIAN S SEWELL LCPC, NCC, OTR/L (NPI 1679796718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679796718 NPI number — VIVIAN S SEWELL LCPC, NCC, OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEWELL
Provider First Name:
VIVIAN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC, NCC, OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SEWELL
Provider Other First Name:
VIVAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FAHEY
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679796718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 973
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTMINSTER
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21158-0973
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-848-5785
Provider Business Mailing Address Fax Number:
410-848-5629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 N. MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONSBORO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-991-5973
Provider Business Practice Location Address Fax Number:
410-848-5629
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 541067300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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