Provider Demographics
NPI:1114967056
Name:LEWIS, RICHARD MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARK
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:719 GREEN VALLEY RD STE 306
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7026
Practice Address - Country:US
Practice Address - Phone:336-275-6470
Practice Address - Fax:336-275-6474
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1779103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5441630OtherAETNA
NC0475KOtherBCBS NC
NC58893OtherMEDCOST
NC5441630OtherAETNA