Provider Demographics
NPI:1265989503
Name:KLEWICKI, LISA (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KLEWICKI
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 1:450 W BROAD ST STE 211
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3318
Mailing Address - Country:US
Mailing Address - Phone:571-277-4919
Mailing Address - Fax:703-241-1122
Practice Address - Street 1:450 W BROAD ST STE 211
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3318
Practice Address - Country:US
Practice Address - Phone:571-277-4919
Practice Address - Fax:703-241-1122
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-03
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002980103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical