Provider Demographics
NPI:1043655236
Name:LEWIS, KENNETH RANDALL (EDD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RANDALL
Last Name:LEWIS
Suffix:
Gender:M
Credentials:EDD, LMFT
Other - Prefix:DR
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EDD, LMFT
Mailing Address - Street 1:1802 N ALAFAYA TRL
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4716
Mailing Address - Country:US
Mailing Address - Phone:407-766-0020
Mailing Address - Fax:
Practice Address - Street 1:1802 N ALAFAYA TRL
Practice Address - Street 2:SUITE 115
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4716
Practice Address - Country:US
Practice Address - Phone:407-766-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 2615106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist