Provider Demographics
NPI:1851939474
Name:EWALT, KHADIJA TAHIRA (LMHC)
Entity type:Individual
Prefix:
First Name:KHADIJA
Middle Name:TAHIRA
Last Name:EWALT
Suffix:
Gender:
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 E COLLEGE AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-3369
Mailing Address - Country:US
Mailing Address - Phone:435-572-0340
Mailing Address - Fax:
Practice Address - Street 1:168 E COLLEGE AVE UNIT C
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-3369
Practice Address - Country:US
Practice Address - Phone:435-572-0340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61625777101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health