Provider Demographics
NPI:1053847251
Name:LEWIS, NICOLE BASHAN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:BASHAN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 W 98TH AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2465
Mailing Address - Country:US
Mailing Address - Phone:219-789-9185
Mailing Address - Fax:
Practice Address - Street 1:1325 W 98TH AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307
Practice Address - Country:US
Practice Address - Phone:219-789-9185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-08
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000389A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health