Provider Demographics
NPI:1265835219
Name:KEITH K. EWELL, PH.D.
Entity Type:Organization
Organization Name:KEITH K. EWELL, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:K
Authorized Official - Last Name:EWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-322-0701
Mailing Address - Street 1:12700 SABASTIAN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6610
Mailing Address - Country:US
Mailing Address - Phone:703-322-0701
Mailing Address - Fax:
Practice Address - Street 1:12700 SABASTIAN DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6610
Practice Address - Country:US
Practice Address - Phone:703-322-0701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002479261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health