Provider Demographics
NPI:1275715955
Name:LEWIS, COLLEEN M (MFT, ATR)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MFT, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 MATCH POINT AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-2523
Mailing Address - Country:US
Mailing Address - Phone:707-292-7784
Mailing Address - Fax:
Practice Address - Street 1:7425 RANCHO LOS GUILICOS RD DEPT B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-6530
Practice Address - Country:US
Practice Address - Phone:707-495-7388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48370106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist