Provider Demographics
NPI:1184029803
Name:LEWIS, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
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 1:2557 CHARLESTON TER
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1855
Mailing Address - Country:US
Mailing Address - Phone:770-841-2132
Mailing Address - Fax:
Practice Address - Street 1:2557 CHARLESTON TER
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1855
Practice Address - Country:US
Practice Address - Phone:770-841-2132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007150101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional