Provider Demographics
NPI:1083747752
Name:LEWIS, CHARLES EUGENE (PHD, LICSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EUGENE
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JEFFERSON ST.
Mailing Address - Street 2:STE. 2C
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504
Mailing Address - Country:US
Mailing Address - Phone:617-379-0496
Mailing Address - Fax:617-807-0958
Practice Address - Street 1:872 MASSACHUSETTS AVE.
Practice Address - Street 2:STE. 2-2, 2-7
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-395-5806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1022091104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker