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General NPI Number Information
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NPI Number | 1265835219
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Entity Type | Organization
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Legal Business Name | KEITH K. EWELL, PH.D.
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Dates
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Enumeration Date | 10/06/2014
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Last Update Date | 10/06/2014
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Provider Practice Location Address
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Address Line | 12700 SABASTIAN DR
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City | FAIRFAX
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State | VA
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Zip | 22030-6610
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Country | US
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Telephone | 703-322-0701
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Fax |
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Provider Business Mailing Address
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Address Line | 12700 SABASTIAN DR
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City | FAIRFAX
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State | VA
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Zip | 22030-6610
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Country | US
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Telephone | 703-322-0701
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL PSYCHOLOGIST
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Name | DR. KEITH K. EWELL
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Credential | PH.D.
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Telephone | 703-322-0701
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 0810002479
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License Number State | VA
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