Provider Demographics
NPI:1114540234
Name:LEWIS, STACEY MICHELLE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
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 1:3771 STEFANI RD
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-7795
Mailing Address - Country:US
Mailing Address - Phone:850-939-4190
Mailing Address - Fax:
Practice Address - Street 1:7552 NAVARRE PKWY
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-7305
Practice Address - Country:US
Practice Address - Phone:850-939-4190
Practice Address - Fax:850-607-6932
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician