Provider Demographics
NPI:1073537379
Name:LEWIS, MARY M (MA-CCCA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA-CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 COUCH AVE
Mailing Address - Street 2:#330
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5568
Mailing Address - Country:US
Mailing Address - Phone:314-965-9184
Mailing Address - Fax:314-984-8019
Practice Address - Street 1:505 COUCH AVE
Practice Address - Street 2:#330
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-5568
Practice Address - Country:US
Practice Address - Phone:314-965-9184
Practice Address - Fax:314-984-8019
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999136547231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000024844Medicare ID - Type UnspecifiedST LOUIS, MO MEDICARE