Provider Demographics
NPI:1245611383
Name:LEWIS, AMY
Entity type:Individual
Prefix:
First Name:AMY
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 1:5102 N 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7312
Mailing Address - Country:US
Mailing Address - Phone:623-229-5660
Mailing Address - Fax:
Practice Address - Street 1:5102 N 61ST AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7312
Practice Address - Country:US
Practice Address - Phone:623-229-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9805101YP2500X
385HR2055X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ9805Medicaid