Provider Demographics
NPI:1083979553
Name:LEWIS, DONNIE BQ
Entity Type:Individual
Prefix:MR
First Name:DONNIE
Middle Name:BQ
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8821 WINDY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-7460
Mailing Address - Country:US
Mailing Address - Phone:405-361-4730
Mailing Address - Fax:
Practice Address - Street 1:10948 N MAY AVE STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-6224
Practice Address - Country:US
Practice Address - Phone:405-751-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2012-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid