Provider Demographics
NPI:1225622772
Name:LEWIS, ERYN ANNE (OTR)
Entity Type:Individual
Prefix:
First Name:ERYN
Middle Name:ANNE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ERYN
Other - Middle Name:ANNE
Other - Last Name:KITTOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:MEDICAL STAFF SERVICE
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-364-4999
Mailing Address - Fax:701-364-8476
Practice Address - Street 1:407 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1950
Practice Address - Country:US
Practice Address - Phone:218-786-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5821225X00000X
MN106491225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN106491OtherMN BOARD OF OCCUPATIONAL THERAPY
MN1225622772OtherNPI