Provider Demographics
NPI:1275630386
Name:LEWIS, MANDI L (PT)
Entity Type:Individual
Prefix:MRS
First Name:MANDI
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21756 STATE ROAD 54
Mailing Address - Street 2:#102
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-6921
Mailing Address - Country:US
Mailing Address - Phone:813-948-8443
Mailing Address - Fax:813-909-2036
Practice Address - Street 1:21756 STATE ROAD 54
Practice Address - Street 2:#102
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-6921
Practice Address - Country:US
Practice Address - Phone:813-948-8443
Practice Address - Fax:813-909-2036
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20237225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106773Medicare ID - Type Unspecified