Healthcare Provider Details

I. General information

NPI: 1356551907
Provider Name (Legal Business Name): FAWN D. HEWITT PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 NW CORVETTE ST.
WALDPORT OR
97394
US

IV. Provider business mailing address

1918 NW CORVETTE ST. P.O. BOX 303
WALDPORT OR
97394-0303
US

V. Phone/Fax

Practice location:
  • Phone: 541-563-6649
  • Fax:
Mailing address:
  • Phone: 541-563-6649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1670
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3269
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: