Provider Demographics
NPI:1538654082
Name:FEDEWA, ALICIA L (PHD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:L
Last Name:FEDEWA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 MOUNT VERNON DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-2217
Mailing Address - Country:US
Mailing Address - Phone:517-285-5928
Mailing Address - Fax:
Practice Address - Street 1:2039 REGENCY RD STE 6
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2334
Practice Address - Country:US
Practice Address - Phone:502-991-8399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY129932103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY129932OtherLICENSE
MI6301019090OtherLICENSE