Provider Demographics
NPI:1003032798
Name:LEWIS, DIANNE LACEY (MCD, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:LACEY
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 SHOAL CREEK FLS
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-3141
Mailing Address - Country:US
Mailing Address - Phone:423-468-4096
Mailing Address - Fax:
Practice Address - Street 1:27 SHOAL CREEK FLS
Practice Address - Street 2:
Practice Address - City:SIGNAL MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37377-3141
Practice Address - Country:US
Practice Address - Phone:423-468-4096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2013-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003612235Z00000X
TNSP0000004940235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000693316CMedicaid
GA000693316BMedicaid