Provider Demographics
NPI:1679796718
Name:SEWELL, VIVIAN S (LCPC, NCC, OTR/L)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:S
Last Name:SEWELL
Suffix:
Gender:F
Credentials:LCPC, NCC, OTR/L
Other - Prefix:
Other - First Name:VIVAN
Other - Middle Name:
Other - Last Name:SEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FAHEY
Mailing Address - Street 1:PO BOX 973
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21158-0973
Mailing Address - Country:US
Mailing Address - Phone:410-848-5785
Mailing Address - Fax:410-848-5629
Practice Address - Street 1:24 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:BOONSBORO
Practice Address - State:MD
Practice Address - Zip Code:21713
Practice Address - Country:US
Practice Address - Phone:301-991-5973
Practice Address - Fax:410-848-5629
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
MD02673225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD541067300Medicaid