Provider Demographics
NPI:1043360761
Name:LEWIS, SUZANNE J (LISW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:J
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3237
Mailing Address - Country:US
Mailing Address - Phone:419-334-6619
Mailing Address - Fax:
Practice Address - Street 1:715 S TAFT AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3200
Practice Address - Country:US
Practice Address - Phone:419-334-6619
Practice Address - Fax:419-334-6671
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 00058711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLESW76831Medicare UPIN