Healthcare Provider Details

I. General information

NPI: 1679796718
Provider Name (Legal Business Name): VIVIAN S SEWELL LCPC, NCC, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIVAN SEWELL FAHEY

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 09/10/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 N. MAIN STREET
BOONSBORO MD
21713
US

IV. Provider business mailing address

PO BOX 973
WESTMINSTER MD
21158-0973
US

V. Phone/Fax

Practice location:
  • Phone: 301-991-5973
  • Fax: 410-848-5629
Mailing address:
  • Phone: 410-848-5785
  • Fax: 410-848-5629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: