Provider Demographics
NPI:1225641335
Name:LEWIS, KENNY E
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:E
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:KENNY
Other - Middle Name:EUGENE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 PINEY FOREST RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2867
Mailing Address - Country:US
Mailing Address - Phone:434-549-5215
Mailing Address - Fax:
Practice Address - Street 1:519 DOWNING DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-5208
Practice Address - Country:US
Practice Address - Phone:434-421-0034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60242223101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health