Provider Demographics
NPI:1104190834
Name:LEWIS, BRANDON SCOTT
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:SCOTT
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 1:1502 S GLOSTER ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6510
Mailing Address - Country:US
Mailing Address - Phone:662-844-0047
Mailing Address - Fax:662-844-0780
Practice Address - Street 1:1502 S GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6510
Practice Address - Country:US
Practice Address - Phone:662-844-0047
Practice Address - Fax:662-844-0780
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health